royal commission into victoria’s mental health system · 2019-07-26 · .25/07/2019 (18)...

.25/07/2019 (18)

Transcript produced by Epiq

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ROYAL COMMISSION INTO VICTORIA’S MENTAL HEALTH SYSTEM

Melbourne Town Hall, Yarra Room,90-130 Swanston Street,Melbourne, Victoria

On Thursday, 25 July 2019 at 10.00am

(Day 18)

Before: Ms Penny Armytage (Chair)Professor Allan Fels AODr Alex CockramProfessor Bernadette McSherry

Counsel Assisting:Ms Lisa Nichols QCMs Georgina CoghlanMs Fiona Batten

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.25/07/2019 (18) A M GREAVES (Ms Nichols)


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MS NICHOLS: Good morning, Commissioners. The nextwitness is Mr Andrew Greaves, the Auditor-General ofVictoria. I call him now.

<ANDREW MARK GREAVES, sworn and examined: [10.02am]

MS NICHOLS: Q. Mr Greaves, are you the Auditor-Generalof Victoria?A. I am.

Q. Before your appointment in 2016, were you theAuditor-General of Queensland between 2011-2016?A. I was.

Q. Before that, did you hold various roles in theVictorian Auditor-General's Office?A. I did.

Q. What did they include?A. I was the Assistant Auditor-General in charge of thePerformance Audit Group more recently, and before that theAssistant Auditor-General in charge of the Financial AuditGroup.

Q. Have you had over 30 years' experience in the publicsector in external and internal auditing at federal, stateand local government levels?A. I have.

Q. Have you prepared a statement at the RoyalCommission's request?A. I have.

Q. I tender the statement with its attachments.[WIT.0001.0064.0001] Mr Greaves, could you explain briefly,what is the role of the Auditor-General as an independentofficer of the Victorian Parliament?A. The primary role of the Auditor-General is to provideassurance to the Parliament about the efficient andeffective operation of the public sector, and indischarging that role I undertake two important functions:my office undertakes financial audits which examine andreport on the reliability of financial information that'sreported by the public sector, but my office alsoundertakes performance audits. In that performance auditfunction we examine variously, either at an entity orprogram or activity level, the efficiency, economy and

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effectiveness of those various activities and the extent oftheir compliance with laws and regulations.

Q. What's the relationship between the Auditor-Generaland Parliament?A. I am an independent officer of the Parliament, andthat is set out in the Constitution Act of Victoria. Ihave a relationship with an oversight committee, which isthe Public Accounts and Estimates Committee. In relationto the Public Accounts and Estimates Committee, theyoversight both my budget and my annual work and I mustconsult with that committee on both of those matters.

Q. What's the relationship between the Auditor-Generaland the executive arm of government?A. The intent, as described and set out in theConstitution and also in the Audit Act, is that I cannot bedirected in the discharge and performance of my duties andfunctions. The intent there is that, as an independentofficer of the Parliament, I am separate from, andindependent of, the executive.

Q. The Auditor-General is not permitted to comment on themerits of government policy; is that correct?A. That's correct. There's actually a legislativeprovision in the Audit Act itself which precludes me fromcommenting on or questioning the merits of governmentpolicy objectives. I take that as therefore a prohibitiongenerally, whether in a report or in public, on questioningthe merits of government policy objectives.

Q. Thank you. Your office has recently published twoaudit reports in relation to the Mental Health Act and themental health sector: the first being Access to MentalHealth Services published in March 2019, and the secondbeing Child and Youth Mental Health published in June 2019,and those two are annexed to your statement?A. They are.

Q. Can I ask you about the Access Report first, what wasobjective of that audit?A. The primary objective of the Access Report, as thetitle would suggest, was to understand to what extent thosewho require it have access to mental health services inVictoria.

Q. What was your overall conclusion, Mr Greaves?

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A. I'll now refer, if I may?

Q. I'll direct you to paragraph 21 of your statement, ifthat assists?A. That will. The overall conclusion was that theDepartment of Health and Human Services has done too littleto address the imbalance between demand for and supply ofmental health services in Victoria.

Q. And in substance, what were your findings in brief?A. The major findings: a lack of sufficient andappropriate system level planning, investment andmonitoring over many years. That the current 10-yearmental health plan outlined few actions that demonstratehow the Department would address the demand challenge thatthe 10-year plan articulates.

That the priority informed areas identified in theplan do not adequately reflect the underlying issue of lackof system capacity and, as a result, the Department hasmade almost no progress in addressing the supply and demandimbalance.

That there are few measures in the outcomes frameworkfor the plan that directly capture performance againstproviding access to services or increasing service reach.

That there is sufficient evidence that there are notenough mental health beds in Victoria to meet current orfuture demand.

That advice from the Department to government,supported by multiple Departmental Commission reviews,clearly articulates the existing funding and infrastructuregaps, but the Department's progress has been slow and themost important elements of change such as funding reform,infrastructure planning, catchment area review, andimproved data collection have only just or not yetcommenced.

That the Department has made little progress closingthe significant gap between Area Mental Health Servicescosts and the price they are paid by the Department todeliver mental health services.

And also, in addressing historical inequities infunding allocations that do not align to current

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populations and demographics.

That the bed day costs of the AMHSs are higher thanthe price DHHS pays, and they do not receive the necessaryfunding to meet demand.

That there are shortcomings in the data collectionsystem including lack of functionality and low usability,which often results in duplication of data collection.

That the Department's approach of approximating demandgives rise to a significant risk that, without theinclusion of data from the triage system and unregisteredclients, the Department does not adequately capture theextent of mental health illness in the population and thetrue unmet demand.

That the public mental health services are subject toan input-based funding model which is not sensitive tounmet demand, the needs and complexity of the mental healthservices client cohort, contemporary population data andall demographic changes.

And that the introduction of activity-based funding inmental health services has been on the agenda in Victoriafor over five years and, although some reform has beenproposed, without adequate quantum of funding and the staffand infrastructure required to deliver those services,there is a risk that the intended outcomes will not beachieved.

Q. Thank you, Mr Greaves. We'll return to those shortly.Can I now ask you about the Child and Youth Mental HealthReport. What was the objective of that audit?A. The objective of that audit was to determine whetherchild and adolescent mental health services effectivelyprevent, support and treat child and youth mental healthproblems. We focused on clinical mental health servicesfor young people with moderate-to-severe mental healthproblems.

Q. What did you find overall?A. Overall, that not all Victorian children and youngpeople with dangerous and debilitating mental healthproblems received the services that they and their familiesneed.

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Q. What were your further findings in substance?A. In substance the key findings were that specialistchild, adolescent and youth mental health services do notmeet service demand or operate as a coordinated system.There is no strategic framework to guide and coordinate theDepartment or health services that are responsible forchild and youth mental services, CYMHS. Problems with theCYMHS performance monitoring system created oversight gapsfor the Department, which leaves it unable to addresssignificant issues that require a system level response.

The Department does not sufficiently understand thesystem and the challenges it faces; its lack ofunderstanding contributes to a climate of uncertainty anddistrust, which inhibits systematic improvement and createssignificant variability and inequity in the care thatchildren and young people receive.

The Department has predominantly taken a one size fitsall approach to mental health systems' design andmonitoring which does not adequately identify and respondto the unique needs of children and young people.

Q. Now, Mr Greaves, the recommendations in your reportdirectly addressed the issues that you found, but you'vesaid in your statement to the Commission that often issuesof that kind are symptomatic of some deeper causal problem.You've conducted a root cause analysis of sorts andidentified two factors that you say are systematic and areworth considering: can you say what they are?A. The two factors which I see as root cause factors, andso first order factors, relate to the role of theDepartment in a devolved service delivery environment, andthe second one is the performance measurement framework andsystems that are used to monitor and measure performance.

Q. Can you address the role of the Department first andsay why you think that is a first order issue?A. The reason I came to that conclusion was, not justlooking at this report, but looking at other reports thatwe have tabled variously since 2005 that relate to theDepartment and also to reports that other people have alsotabled in relation to the Department, such as the DuckettReview; which point to a longstanding debate, if you like,about what is the proper role of the Department as thesystems steward, as it is now variously described, or thesystem owner, vis-à-vis the service delivery arms which are

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the health services themselves and those that are out inthe community health space.

So we asked ourselves during those two reports thatwe've mentioned why certain actions hadn't been taken, whyreviews and reports had continually raised issues, and yet,there did not seem to be any response to those issues.

And in those reports and in other reports that Ireferred to, such as most recently the report we did on theright of private practice arrangements in public hospitals,we have often had the response that "it is not our role",this being the Department, "it is not our role". Andvariously when we ask, in terms of that role, the onefactor that in my experience stands out is the monitoringand oversight of the system.

I know previous Auditors-General have characterisedthis as an oversight deficit. And so, we've had a debate,a longstanding debate between Auditors-General and theheads of those agencies about, to what extent is itnecessary and appropriate for the centre, the Department,which effectively sets policy, sets strategy, funds thesystem, to then monitor and oversight the system tounderstand to what extent strategy is being given effectto, how well those funds are being used.

But more importantly, in the context of providing fulland frank advice to the government of the day, how wellinformed is the Department about present system capabilityand present system performance.

And it's not consistent, but variously we've had thesedebates over the years about, to what extent should I bemonitoring, I being the Department, to what extent shouldwe be monitoring, to what extent should we be oversighting?

Quite often we hear, "Well, it's a devolved system",and in the devolved system we let the managers manage.It's not appropriate for us to say how they should spendtheir money. We don't always see that policy consistentlyapplied anyway.

But my deeper and perhaps more systematic problem thatI have with this goes to this whole issue of appropriateaccountability: where should the accountability lie for theoutcomes that are being achieved by the system?

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And the features that I see specifically that areexhibited in the health and human services system relate tothe funding of that system, and in two parts: theoperational funding - my reports identified that the amountof funds that are being provided to the health services donot cover the cost of the provision of those services.

The other feature of this system, of course, is thatthe capital funding is entirely controlled by theDepartment, that the health services obtain operationalfunds but capital funding is a separate matter. So, interms of planning for infrastructure and delivery ofinfrastructure, accountability should properly rest withthe Department in my estimation, and I also wonder how youcan properly hold the health service to account, knowingthat you haven't fully funded them to deliver the servicesyou've asked them to deliver.

And, while it is appropriate to say that the hospitalis the best place to manage access, they are in one sensebest placed to manage access because they are the serviceproviders, but in another sense, if they have toeffectively rob Peter to pay Paul to actually pay for that,then they're not best placed to manage access, so thesystem owner must take some accountability andresponsibility for that. And so, this to me is asystematic matter that we need to consider in the wholedesign of the system: where does the accountability sit?

Q. Can I just take you back, Mr Greaves, and ask - andyou've been expressing a number of these things in the formof questions: can I ask for your views about where theaccountability should sit, or perhaps put a different way,you referred to an oversight deficit before. What shouldbe the characteristics, in your assessment based on yourexperience, of the oversight and leadership function of theDepartment in relation to mental health?A. Well, oversight is predicated on obtaining theperformance information you need, the service performanceinformation you need, to understand service performance,and of course to obtain information about the outcomes orthe impacts of the delivery of those services.

So, accountability must sheet home to the Department,for establishing appropriate systems, to capture thatinformation and aggregate that information. I note in the

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Child and Youth Mental Health Audit that we undertook ananalysis of three years worth of data across five healthservices, and my team advised me that this was the firsttime that that data had actually been analysed. And, ofcourse, I wondered to myself, why would that be the case?This data has been available.

And while individual health services may have itwithin their own power to analyse their data, they don'thave it within their power to join their data together andtake a system view, and so again, accountability for thatsystem performance must sit with the Department in terms ofits oversight role.

Q. Can I ask you about the debate that you mentioned, theongoing one between the Auditors-General and theDepartment. I think you've expressed the Auditors-Generalposition generally. As you understand it, and theDepartment will speak for themselves later today, but justhistorically what has been the division point in the debatebetween Auditors-General and the Department?A. Well, quite simply, a disagreement about this need tooversight system performance. It really goes to a devolvedservice delivery model and what is the proper role of theDepartment in that. I might say that this is not just afeature in my experience of mental health or human servicesin health generally, it's a feature more broadly ofgovernment where the centre is less inclined to want totake responsibility for the delivery of services.

Q. In relation to the question of performancemeasurement, in your statement you said:

"The Department's mental health KPIs do notassess whether consumers are accessingappropriate mental health services or trackthe performance of their 10-year plan interms of access Victorians have to mentalhealth services."

That wraps up two concepts: the first is related toKPIs, can you tell the Commissioners what you mean by that?A. What KPIs are, or what we mean by --

Q. No, what you mean by your conclusion that the mentalhealth KPIs do not assess whether consumers are accessingappropriate services?

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A. Well, basically when we looked at the suite of KPIs,we couldn't find ones that spoke to that. The predominantobjective of the Access Audit was to evaluate access.

Q. Access, yes.A. And obviously in the mental health plan, when we readthrough it, it was made clear that there was a major issuein terms of access because of the growth in demand, and so,we would expect in any performance indicator frameworkgiven that this was specified as one of the majorchallenges for the system, that you would want to have agood suite of indicators that spoke to access, so it wasthe absence of indicators.

Q. In your assessment, what kind of performanceindicators would be capable of better assessing access?A. In the report we referred to some other indicatorsthat could speak to access, and we're particularlyinterested in the data that may and should be beingcaptured by triage services about the people that aredenied access. So, to me, that is a prime indicator andsomething that I would be interested in understanding more,particularly to understand the unmet demand.

Q. You also say in your report that getting the rightperformance indicators is only really half of the story.The other one is what you measure, and you've said that, ifperformance indicators are to be used to drive strategy andevaluate the effectiveness of planned actions, they musthave targets against which progress can be measured: canyou elaborate on that?A. Indeed. Yes, and my concern here is, and we go backto systematic issues, we can see through the mental healthplan that we've been working on outcome measures andoutcome indicators now for a number of years, but notinformed by any overarching government policy or strategyin relation to an outcomes framework.

Most recently we are aware through the Department ofPremier and Cabinet that an outcomes framework document hasbeen published.

My concern, looking at both the outcomes that wereexpressed in the mental health plan and the outcomes thatare now being expressed more recently in the strategic planof the Department and its new outcomes measures framework,and in the government's document about the outcomes

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framework more broadly, there is very little, if any,reference to targets. So, we are concerned, or I amconcerned, that in the absence of targets it would bedifficult to discern a range of matters.

First and foremost, what is the performance gap? Whatis it that we're actually trying to achieve? So we canhave an outcome measure, we can have an output measure, butif we're not saying to ourselves, what do we want toachieve, and in what timeframes such that you could expressa target as a three-year target or as a 10-year target, orin fact both, you could express a target on a finaloutcome, for example the government in its suicideprevention strategy has articulated a 10-year target ofreducing suicide by half.

So, it is not as though targets have not beenexpressed, but the frameworks that are being promulgatedand the outcomes documents that I have seen seem to avoidtargets. So, how will the outcomes framework be somethingthat organises a response that allows us to make fundingdecisions in the absence of a target?

So that's my primary concern. I think in any outcomesmeasurement framework, you need obviously to express theoutcome you desire but, if you don't actually tie a targetto it, I think you're missing a key part of theaccountability equation.

Q. What, in your view, are the characteristics of usefultargets?A. Well, the characteristics of useful targets first andforemost stem from the characteristics of usefulindicators. In Victoria, of course, we've had an outputbased budgetary framework for a number of years, but thathas focused on service outputs: time, cost, quantity andquality, and have had targets expressed in them, but I mustsay some of those actually speak a bit more to outcomes tome than they do to outputs.

Q. Can you give an example?A. I could actually refer to the Budget Paper 3 which hasthe mental health outcomes expressed - or output statementexpressed in it, if I could find that.

Under a quality measure in BP 3 - this is from the2019/2020 service delivery statements on p.208 - one of the

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quality measures is new client index. Now, that new clientindex has actually been described in the outcomes frameworkthat's been promulgated by the Department.

So, first and foremost, I'm seeing, we're developingan outcomes framework here, we haven't really gone back andthought about the outputs framework and the interactionbetween the two. And so, there's probably somerationalisation required and maybe the Secretary ofTreasury and Finance could speak to how the new outcomesframework is being integrated and coordinated with theoutputs budgetary framework. But that outputs frameworkhas long had targets.

When we come to outcomes, in my experience peopledon't like expressing targets for outcomes because outcomestypically take a long time to emerge, and they'll emerge ina longer timeframe than normal political cycles, so you canunderstand a natural reluctance to express an outcome,because you can't necessarily demonstrate improvement.Sometimes the actions that you take now may take, three,four, five, seven years to actually show an impact, whichshouldn't be a reason for not expressing the target, andI've mentioned the suicide target. But what we should tryto do when we're defining a good target is to define a goodmeasure.

In New Zealand, not more recently with their wellbeingbudget but the performance measurement framework thatpreceded that, they had most success in definingintermediate outcomes, and the idea of an intermediateoutcome, or part of one of the ideas of an intermediateoutcome, is that the time between the action and the effectis less.

And so, for example, access to mental health servicesis a good intermediate outcome. If I can get those peoplewho access mental health services up from the 1.1, 1.3,1.5 per cent, whatever the figure is, to 3 per cent, whichis the estimate in the population of people that requireaccess, that is an intermediate outcome.

I can express that, I can express a clear target inrelation to that intermediate outcome and I can tie backactions that we're taking to move that rate up to3 per cent. So, yes, a target to me should be quitespecific, clear, measurable, but I think it's best

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expressed in this new framework as intermediate outcometargets rather than final outcome targets.

In fact, you could mount an argument that youshouldn't have a final outcome target per se, because it isso uncontrollable, there are so many confounding orconflating variables that you can't really mobilise aroundthat target.

Q. If that example is an intermediate outcome in yourhypothetical world, what would be the ultimate outcome byreference to that intermediate outcome?A. Well, I think the ultimate outcomes are expressed inthe framework at the moment: the improved mental health ofthe Victorian population and the reduction in the suiciderate. You will see those also referred to in the report ongovernment service delivery outputs framework. So I thinkthere's not much debate about the long-term final outcomeswe're trying to achieve, but let's make sure we're reallyclear on what the intermediate outcomes are and link thoseto the outputs.

Q. And in your view they should be linked to the outputsincluding for the purposes of Budget Paper 3?A. I'm trying to discern how the outcomes framework asit's currently designed - and I haven't audited this yet sothis is my observation based on what I've read - I'mstruggling to understand how it will feed into thebudgetary process.

Again, if I reflect on the New Zealand experience withtheir 10 key result areas, absolutely focused onintermediate outcomes, and funding was directed towardsachieving those. We were all - well, not all of us, butJacinda Ardern was here last week talking about the newwellbeing budget which seems, again from a distance, to tryand enshrine the idea of tying the budgetary process to theoutcome.

People will have different views, and governments willhave different views, about whether we need an outcomesbudget framework or an output budget framework. I'm notbarracking for either one: you know, is it stillappropriate to fund outputs to, say, the services that aredelivered and have your funding directed toward thedelivery of outputs; but, in making those decisions aboutwhich outputs are provided, the design of the output, the

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quality of the output, you can be driven by considerationsof the outcomes you're trying to achieve and thepriorities.

Now, that's the other thing in my estimation that'spresently missing, that the Department has done good workin this outcomes space and the mental health plan isarticulating outcomes, and these more recent strategicplans and strategies are articulating that, but I don'thave a sense yet of any top-down strategic prioritisationby the government. So, it's good to articulate outcomesdown at an individual agency level, but where do they fitin terms of the government's overall priorities? And thatalso seems to me to be missing from the current outcomesframework.

Q. I see. And, it's the Department's role to articulatethat framework including the links between outputsparticularly?A. Well, I think it's more than the Department's role; Ithink it's the public sector's role to advise thegovernment on the appropriate design of an outcomesframework, and if the words that we read in the outcomesframework are to be given effect, that it's going tomobilise resources, that it's going to help drive actions,there must be some linkage then into the budgetary process.So, I think it's incumbent on the public sector generallyto advise government about the appropriate design of thisframework.

Q. Can I just ask you a question about targets finally.Ms Peake will give some evidence later today about targets,and she'll say this:

"There are important limitations in the useof targets, especially for complex servicesystems. These include risks that numerictargets [among other things]: prioritiseactions that are more easilymeasurable ... change peoples' behaviour,with perverse results; narrow a reformfocus, inhibiting system levelintegration ... are set to the wrongdriver ... [and] reduce flexibility tochanging evidence or contexts ..."

Do you have any observations on that evidence?

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.25/07/2019 (18) A M GREAVES


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A. My first observation is that the risks that arearticulated there are within the control of the agency andwithin the control of the government.

So, simply saying that there are risks attendant uponsetting targets is not a reason not to set targets. Ifwe've named the risk, we manage the risk. Yes, and we haveseen measures, more importantly, than targets that cancreate perverse behaviours.

So, it's in the design of the measure and the settingof the target that is what is important, but again, Iwouldn't argue that's a reason not to set the target,because the benefits of setting targets which really aresupposed to drive action, drive strategy, track progress,in my estimation far outweigh the risks associated withsetting targets.

MS NICHOLS: Thank you, Mr Greaves. Chair, do theCommissioners have any questions?

CHAIR: Q. I might start then. Thank you very much,Mr Greaves, for your overview and for your submission andattached information.

When we look at this issue about accountability withinthe public sector for service delivery design,implementation and the like, the way that you've describedit, given you have a whole-of-government view, can youassist the Commission by identifying where you've seen goodpractice that you would alert us to and where you think theaccountability frameworks are operating well.

MS NICHOLS: Chair, could you speak closer to themicrophone?

CHAIR: Do you want me to repeat the whole lot?

THE WITNESS: No, no, I got that, Chair.

CHAIR: Q. So, really where there are examples of bestpractice, you use New Zealand, but closer to home in theVictorian public service, for example, or elsewhere inAustralia?A. I mean, I use New Zealand because it's the most recentand obvious example. I'm not sure that I can point tobetter practice. Given what I've said about the current

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.25/07/2019 (18) A M GREAVES


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limitations of the outputs framework and the nascentoutcomes framework in Victoria, I don't think there's areasthat I could really point to that would speak to this beingdone well.

One of the features of the New Zealand framework thatI'm attracted to, and there was actually an evaluation doneof this, a report on it, talked about "blindaccountability".

What that related to was that, we spend a lot of timetrying to - or get very vexed about trying to attributeactions to outcomes, and the point of the New Zealandframework was that, don't get caught up in attribution, andyes, it's going to be unfair, but where you have issuesthat are cross-government, basically the important thing isto get collective responsibility and accountability for anoutcome and get the resources mobilised to deliver on thatoutcome, and whether or not your organisation contributes5 per cent of the outcome or 95 per cent of the outcome isactually irrelevant at the end of the day.

So, there's unfairness in it, but the evaluations inNew Zealand suggested that nevertheless it worked, and thatthey could point to improvements in those areas that theyfocused on, those 10 key result areas.

So, to me, that is still a model of better practice.Now, we have here the Victorian Secretary's Board, and wehave conversations now about 1 VPS, and we are moving tobring together our administrative datasets, aggregate themand analyse them, so I think they are all pointers in theright direction, but I still see missing from thisoverarching, top-down prioritisation of outcomes.

Q. Can I also go back to the fact that, obviously theCommission's had the opportunity to read both of thereports that you've recently tabled in relation to mentalhealth. In both of those reports you make a number ofrecommendations for change that you think need to occur inthe short term as well as over the longer term.

What role will you have in following up in terms ofwhere action is at on those recommendations, and are youalready engaged in dialogue about that?A. We're engaged in dialogue to this extent: the practiceof my office now is to annually write to every agency that

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.25/07/2019 (18) A M GREAVES


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we make recommendations to and ask them to update us on howthey are going implementing those recommendations.

I propose this year in fact to make that reportpublic, so we'll be writing to all agencies, including DHHSand those involved in those two audits, we'll be askingthem to tell us what they've done, what action they'vetaken, whether they continue to accept the recommendation,or whether or not our recommendations have been overtaken,for example, by the Royal Commission, with a view to makingthat a public document.

Q. Given the nature and extent of some of the concernsyou expressed in both of those reports, both about theaccess and the overarching system around child andadolescent mental health, do you have a sense of what's arealistic timeframe whereby you would like to seeimprovements across those service systems addressing theissues you've highlighted?A. To answer the question, what is a realistic timeframe,it really needs to consider what is the funding availableand the priorities of the government. So, I don't thinkit's for me to try and second-guess where the governmentmay want to put its funding against all its otherpriorities, and so, it's probably not appropriate tospeculate what would be an appropriate timeframe. Clearly,those who aren't getting access would like access now.Now, that's not achievable given what we understand to bethe limitations in terms of infrastructure, funding andstaffing.

To what extent the government mobilises resources toaddress the infrastructure deficit, the workforce strategybeing implemented and the funding of the services, willthen impact on how long it actually takes to address it.

Q. Can I confirm from that, your expectation, though, isthat the Department would have a plan that it would put togovernment about how it thinks it should address yourconcerns?A. Absolutely. We think the Department should alwayshave a plan because it's already been informed over anumber of years about the problems in this. So, yes. Mostrecently, our report's raised it again. We would expectthat there would be a plan which would be timed andresourced, I guess, is the more important matter.

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.25/07/2019 (18) F A TOPP (Ms Coghlan)


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CHAIR: Thank you.

MS NICHOLS: May Mr Greaves be excused?

CHAIR: Yes, thank you very much for your witnessstatement and evidence today, Mr Greaves.

<THE WITNESS WITHDREW

MS COGHLAN: The next witness to be called is FelicityTopp, and I call her now.

<FELICITY ANNE TOPP, affirmed and examined: [10.40am]

MS COGHLAN: Q. Thank you, Ms Topp. You've made astatement to the Commission?A. That's correct.

Q. I tender that statement. [WIT.0002.0021.0001] You arethe Chief Executive Officer of Peninsula Health?A. That's correct.

Q. And you have the following qualifications: a Diplomaof Applied Science in Nursing?A. Yes.

Q. A Critical Care Nursing Certificate?A. Yes.

Q. A Bachelor of Nursing?A. Yes.

Q. A Graduate Diploma in Health Counselling?A. Yes.

Q. A Master of Public Health?A. Yes.

Q. And a Vincent Fairfax Fellowship in EthicalLeadership?A. That's correct.

Q. You started your career as an intensive care nurse?A. Yes.

Q. You have 34 years of experience in the public healthsystem to date?

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A. That's right.

Q. You have been in management and leadership roles forapproximately 50 per cent of that time?A. That's correct.

Q. Being since 2001?A. That's right, so I've worked mainly in operationalroles in my leadership experience, and I've been in a ChiefExecutive role for the last 18 months.

Q. Can I just ask you about that in terms of, you say inyour statement that your experience with the mental healthsystem has been with two public health services. You'vejust mentioned your current role; what about before that?A. So, interestingly, I've had the experience across thewhole health system in that time, but my exposure to mentalhealth has been quite limited. I had a three-monthsecondment to Barwon Health back in 2017 to assist themthrough a significant period of change, and I was given theopportunity to take on an executive leadership role for themental health service over that three-month period. Andnow as a Chief Executive Officer, we've got a large mentalhealth service down on the Peninsula.

Q. How long did you say you'd been the CEO of Peninsula?A. Just on 18 months.

Q. But you do come to that role with extensive experiencein health generally?A. Absolutely, yes.

Q. Can I just ask you some questions about the operationsof Peninsula Health, we won't spend much time on this, butjust to get an idea of the services. Firstly, just inrelation to delivery of public health care services and thecatchment, just address that issue?A. So, we provide health care services across thecontinuum of care; I kind of describe it as birth to end oflife. We have 850 square kilometres along the Peninsula,from Carrum, Langwarrin, all the way down to Portsea andthen across to Hastings. The service has 6,000 employees,800 volunteers, and like I said, we provide a continuum ofcare. We've got aged care services, mental healthservices, acute services, community services.

Q. Can I just direct your attention to the mental health

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services, and can you just broadly summarise what they are?A. So, we have an acute inpatient unit and a highdependency unit, aged care inpatient unit, psychogeriatricservice. We have a number of community mental healthservices. We have some specialist services and residentialservices.

Q. Could I ask you about a particular aspect of yourstatement where you say this:

"Until March 2019 mental health services atPeninsula Health were overseen by a ChiefOperating Officer."

But things have changed since that time?A. That's right.

Q. Can you just detail what that change is?A. Yep. So, late last year the Chief Operating Officerwho was overseeing our mental health system as an executiveleader resigned, so we had the opportunity to reconsiderthe executive portfolios within the organisation.

During my first eight months at Peninsula Health, Ihad identified that there were perhaps some significantissues in our mental health service, so there were someleadership issues, some quality issues, so we made thedecision to align our Mental Health Program to ourExecutive Director of Nursing, Midwifery and Allied Healthwho has extensive mental health experience. So, we madethat change and that executive has been leading the programsince February this year.

Q. What's been the benefit of that?A. Well, it's been a terrific support to me, becauseagain, I don't have that huge experience in mental health.It has really allowed us to spend a lot of time with ourstaff, understanding their current issues that they'reexperiencing, listening to them in trying to understandwhat changes we could make within the service that wouldsupport them in delivering the care that they want todeliver.

We've also spent a lot of time integrating ourorganisational clinical governance framework into themental health system, and really concentrating on bringingour mental health team into the rest of the organisation.

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Q. Can I just ask you about that; that one of yourobservations when you first began was that mental healthdidn't have that attention.A. Look, I don't really know whether it didn't have thatattention, because I wasn't there, so it's kind of hard forme to know. I think the executive who was leading themental health service before I arrived absolutely gave theservice considerable attention; had a fairly heavyportfolio, so what we've done is, we have decreased theportfolio a little bit so more time from an executive canbe given to the mental health service.

So, yes, I think that structural change has made a bigdifference, but there's also been some other things thatPeninsula Health has done to engage the mental healthservice closer in with the whole health service.

They undertook, and this is before I arrived, so I'lltake no credit for it, but they undertook a process ofreviewing the access for mental health services and accessacross the whole acute service, especially from ourEmergency Department point of view, and they created asystem of huddles. So, each unit will have an earlymorning meeting at 8 o'clock to find out what's happeningin their area in 24-hours and looking forward to that day,identifying issues of quality, staffing, any lost time toinjuries or staff issues that might have occurred; anypatients that are requiring extra support, et cetera, andall that information comes up to an executive huddle whereall the Directors and the executive meet for 15 minutesevery day and we work through, unit by unit, what'shappening.

I go to those meetings whenever I can, and in15 minutes I can get an understanding of what's happeningin the organisation.

Now, we act on issues at that time as we hear issues,and I think what's been good from a mental health servicepoint of view, is that every day they're engaged in thewhole organisation discussion about issues and concernsthat they have, and I think that's really exposed the wholeorganisation into understanding our mental health servicemuch better.

Q. Alright, I'll come to ask you a bit more about that

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understanding, but can I just take you back to ask youabout the Statement of Priorities, Peninsula's strategicplan and annual business plan. I'll ask you to say alittle bit about each of those, but just in relation to theStatement of Priorities, you've said how long you've beenthe CEO of Peninsula, but you have extensive experienceotherwise in relation to the preparation of the Statementof Priorities?A. I'll take you through the experience and the processof this year's Statement of Priorities, which is the sameprocess that I followed at Barwon.

So, we of course have our strategic plan, ourfive-year strategic plan which is set and developed by theBoard, executive and the whole organisation. We run anannual business plan that is aligned to the strategicobjectives of our strategic plan, and we work that upbefore we receive the guidelines from the Department ofHealth on the Statement of Priorities.

The Statement of Priorities are the government'spriorities that align to their strategy, and we are veryeasily able to accommodate actions against governmentStatement of Priorities through our business plan process,so we're not so dissimilar in being able to complete thoseStatement of Priorities.

One of the questions that you have asked is aboutwhether mental health is featured in the Statement ofPriorities. Through the process of just undertaking ourown business objectives for the year, our own business planwould have a number of actions related to mental health,and the mental health team have their business plan.

So therefore, if there are broad objectives within theStatement of Priorities regarding diversity, AboriginalHealth, occupational violence, then we would be includingmental health objectives within those statements.

Q. So, the drivers or I guess the framework for you toinclude mental health objectives through the Statement ofPriorities is through those other processes that you have?A. Yes.

Q. What about in terms of the extent to which, in yourexperience, the Department of Health and Human Services hasprioritised mental health in the Statement of Priorities?

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A. This year they have got a set objective on mentalhealth access in the Statement of Priorities. Myexperience, and from memory, that would be the first timeI've seen specific objectives in the Statement ofPriorities for mental health.

Q. In your view, is the inclusion of specific objectivesabout mental health within the Statement of Priorities aneffective way of achieving improvement in mental healthservice s?A. In the absence of anything else, of course it wouldbe. If an organisation has a strategic plan and has abusiness plan process, and is prioritising services ofwhich mental health services are a very big service atPeninsula Health, then perhaps the Statement of Prioritiesare not so much a driver, but in the absence of any ofthose documents, then yes, the Statement of Priorities areimportant.

And, the Statement of Priorities are the key documentthat the Chair of the Board signs off with the Minister forHealth, so from a Board perspective they are always verykeen to see what the objectives are in the Statement ofPriorities.

Q. In terms of the Statement of Priorities and the ideathat - I'll take you to a portion of your statement, thisis at paragraph 28. You say that in your experience theSOP, or the Statement of Priorities reporting framework,focuses on acute physical health care and has notadequately addressed mental health care. So, that's yourview?A. Yes, that's right.

Q. And so, the way that Peninsula Health deals with it isto have a good strategic plan and the annual business planto ensure that mental health is appropriately prioritised?A. And supported.

Q. And supported?A. That's right.

Q. You talked about the strategic plan and the annualbusiness plan: are you aware of whether those things werein place prior to you becoming the CEO?A. There were some annual quality and safety plansdeveloped by the directorates, and they were reported up to

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1719

the Board; the detail of those, I'm not completely clearon.

Q. So, did you drive the change towards the strategicplan - perhaps you and others - and this annual businessplan?A. Yeah, so I've changed the process a little bit. So,we've always had a strategic plan and we've just completeda new strategic plan. So, yes, so I brought in a newframework of bringing in the strategic objectives and thebusiness objectives aligned for an annual plan and aligningthose to the Statement of Priorities. So, I've justcompleted that now for this year, and that plan, so thebusiness plan and the Statement of Priorities, are going tothe August Board meeting.

Q. And so, from your perspective, what drove that change?A. Because I'd seen it work elsewhere. So, probably backat Royal Melbourne Hospital actually, at Melbourne Healthwhen I was there, there was a process of developingcomprehensive business plans. I felt - and like to usethem, I suppose, from a Directorate level for me and theteam.

And then, when I had the opportunity to go to BarwonHealth, we shamelessly took Western Health's framework,which had evolved somewhat since we used it at Melbourne,and then I've just taken that same framework to Peninsula.Modified it a little bit.

Q. Can I just ask you now about prioritisation by theBoard. You say in your statement, and this is atparagraph 33:

"I believe that the Board of a healthservice can, at any time, ask the executivemanagement to prioritise mental healthservices as with any service."

So, there's the capacity to do so. How readily doesit happen and what are the impediments?A. So, I think boards can ask executive questions at anytime, and they often do. I think Boards do rely onexecutive management to give them adequate information andcoherent information to advise them on what's happening inthe health service. If they don't get that information,they won't know.

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So, you have a Statement of Priorities and the reportsthat you get from the Department of Health: if that's allthat's going up to board, then that's all they would get tosee. That's not what's happening at Peninsula Health.We've got a number of reports from various groups withinthe organisation that go up to the Board level fordiscussion.

The other observation that I have is that, we do spenda bit of time educating boards on clinical governance andtheir roles and responsibilities, but to my knowledge Ihave not seen ever mental health services used as anexample of educating boards about what theirresponsibilities are within the mental health services.

We might talk about this a little bit more later but,I have found mental health services quite complex tounderstand. So, I don't completely understand what it isthat we are trying to achieve within our mental healthservice. I kind of get acute health, I get subacutehealth, I get aged health, I've had those experiences, andthose models of care are fairly consistent across thesector.

But just in my two experiences between Barwon andPeninsula, the two different programs are quite differentand, therefore, navigating that as an executive - and evensome of the staff are unable to articulate what the modelsof care are - makes it then quite difficult to be able toeducate and support a Board in understanding what therequirements are for us to be providing safe quality carein our mental health services.

Q. And so, you've had the two experiences that you'vedescribed at Barwon and then your current role, but youdon't see that problem, about there not being a clear modelof care, as a product of the fact that you haven't hadextensive experience in the area? So, the fact that youdon't understand it is not because of the time that youhaven't had to get across it, it's because it's hard tounderstand?A. It is hard to understand. Well, it's hard to have thepeople who are working in the system to describe it to you.

Q. Can you provide an example?A. Okay. So, if I was to speak to a group of mental

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1721

health clinicians, and if I ask them to, say, explain to mewhat the model of care is from going through the EmergencyDepartment to acute unit, back out in the community, andwhat a consumer should expect through that process. Iwould get different points of view. And, I get differentpoints of view from the same clinicians working in the samearea.

So it's hard to a get an understanding, at my level,of exactly what the models of care are in each of thecomponents of the services that we provide. And when I say"models of care", it is down to numbers of patients, howlong patients stay, the treatment and support those clientsget, what the staffing numbers are, so how many staff do weneed to provide that care?

And this is the process that we've just gone throughto try and develop the budgets, because we need to do allof that to then say, okay, well, does the budget match?So, what are those staffing models, what are we trying toachieve, what are the outcome measures we're trying toachieve, what are the performance indicators, okay, andthen what staff do we need to achieve all that? Then, havewe got the environment to do that in, have we got thephysical infrastructure to do that? So, yeah, that's theprocess that we've just worked through.

Q. I just want to ask you about that in greater detailwhen we get to it. If we can just stick for the momentwith prioritisation by the Board, I just want to ask youthis question: what factors do you see that would influencethe level of attention given by the Board to mental healthservices? In particular, does it need a champion?A. Does it need a champion? I think, in the lack of goodinformation and good outcome measures, yes, it needssomebody who - it helps having somebody who knows whathappens in the mental health service, and that can be anexecutive as well as a Board member. Because it is socomplex, it is helpful to have somebody at a senior levelwho does understand mental health services.

Q. One of the things you mention in your statement isthat the KPIs aren't enough to understand the deliverablesor performance outcomes for mental health?A. Not at all.

Q. And that a large amount of data that is collected at

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various levels that is not provided to the Board?A. That's right. Well, not at Peninsula Health at thispoint in time. So, we have the Statement of Priorities'KPIs presented to the Board, we also report occupationalviolence information, serious incidents will go up to theBoard. We also take any internal/external reviews ofservices, we would take up to the Board, so that's what weprovide in mental health.

But I am aware of a large amount of data that ourteams collect, but that data at this point in time is notbeing analysed and is not reported up to the executive orthe Board, but we are in the process of just reviewing allof that.

We've had an external clinical governance review tohelp advise us on what would be some good outcome measuresand indicators that would give myself and the Boardreassurance that we are providing safe, personal, effectiveand connected care for all our clients coming into thehealth service.

Q. And that is an initiative led by Peninsula Health andnot driven at all by the Department of Health and HumanServices?A. No, that's us.

Q. Can I then move on to ask you about oversight by theExecutive Leadership Team. You may have already covered alittle bit of this, but as the CEO, what kinds of regularperformance and activity information about mental healthservices do you receive?A. So, look, I pretty well much receive the same level ofreporting that at this stage goes to the Board, and so,that's why I'm pursuing to get a little bit moreinformation through this clinical governance review.

Q. So, you've recognised that you need more information?A. That's right.

Q. And that things that you want to know about, there'sno information about them?A. Can't get them. No, that's right. And, look, I haveto say that a lot of the measures that are being currentlycollected are very much process and performance measures.And we have similar constraints in our acute healthservices, although I think the physical health services

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have evolved much further than mental health.

I think one of the things that we really do want toconcentrate on now, across all our services, is to haveoutcome measures that are not only meaningful to usproviding the service, but to the consumers who arereceiving the service, and there are not very good outcomemeasures for physical health or mental health on thatexperience. So, I'm looking forward to doing that piece ofwork, but it does need to be done.

Q. You've just touched on there, I guess, some of theparallels with physical health and mental health. There ismore comprehensive data monitoring in relation to physicalhealth?A. Yes.

Q. One of the things you refer to in your statement is acomprehensive dashboard monitoring of a number ofperformance metrics?A. That's right.

Q. And that is something that you would also seek to doin mental health?A. That's right.

Q. But there needs to be more, in your view?A. That's right. So, I think physical health haveevolved their reporting frameworks to a much greater extentto what I'm seeing in mental health. Now, there might beother mental health services that are far more advancedthan the two services that I've had experience with.

But certainly physical health, KPIs, dashboards andprocesses are very similar and you can benchmark. So, Ican look at an ED performance dashboard at any one of thehospitals and get it, understand it, and you can almostfeel it because you understand it, and same with waitinglists and outpatients.

But I don't get any comparative data really - there'sa little bit on the Statement of Priority KPIs which arelimited for mental health - but there's no other KPI orbenchmarking that happens across the mental health service.

So, you know, our community care unit: I've got astaffing profile, but there's no comparison about the types

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of clients, number of clients, how long they stay, what theoutcomes are coming from those areas within our mentalhealth service.

Q. Can I next ask you about funding and prioritisation,and ask you this question: how does Peninsula Health'smental health activity and performance results impact onfunding quantum or activity forecasts or targets insubsequent years?A. So, let me just go through the process, okay, becauseI think that's kind of easier to explain. So, we startedour budget process back in March for the whole organisationand we run the same process across all services. So, weessentially give people a starting budget and that'susually based on what we know or think we're going to getthrough discussions with government. Within the startingprocess there will be some productivity savings, we'll knowthat there will be some grants that start and finish, so wehave a starting point.

Each service builds the budget up from, you know,bottom-up and top-down, and that bottom-up is workingthrough what I was discussing before, what's the model ofcare? So in our acute unit, how many staff do you need,AM, PM, night duty, how many staff have you got? Okay,that's your EFT, all the other bits and pieces you add -that's your budget.

When you get government's budget, you try and matchthat up and that's probably the most difficult part becauseit's very difficult to match what's actually happening in aservice and the budget received. So that's the processthat we're working through at the moment.

All the money coming in for mental health stays withinmental health. So, I don't take mental health money andsay, I'll put that to the outpatient department, so weringfence the mental health funding, and it's quite aprocess to try and match the funding coming into theorganisation to all the specific programs. And, it doesn'tmatch. Like, the acute services funding does not fullycover the staffing profiles and the costs of running theacute services.

Q. Can I ask you a bit more about that. You've touchedon cross-subsidisation when you said that you don't takemoney from mental health and put it into acute services,

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for example, so I guess conceptually one thing is takingmoney from mental health to put it into physical health.

So, would you say that there's no cross-subsidisationin that context, if I can just stick with that point?A. I can say there's - no, so I'll work through that abit. So, we ringfence the funding for mental healthservices and we try and make that funding balance for thoseservices that we're providing.

Now, we do receive throughout a year specified grants,and sometimes they come quite late in the year, so it'salmost impossible for you to recruit and get the staff andexpend those funds. So, you might end up with a surplus offunds in your Mental Health Program that would then hit thebottom line from a reporting framework and then, if therest of the health service is over budget, then thatsurplus would offset that overrun.

So, it's not purposeful "I'm going to use mentalhealth money to cross-subsidise the physical healthservices", because my responsibility is the whole healthservice, so you're trying to balance the whole budget, andso, it might on occasion result in that happening.

I can go into why, and also why it might happen: it'snot only the extra funding that we might get coming inthrough the year, but it has been incredibly difficult torecruit into the positions that we have available in ourmental health service. So, we might carry a significantamount of vacant EFT because we're unable to find thequalified staff to work in those programs, and as a resultthat would then result in a surplus if it doesn't getoffset by the overrun that we have in our acute mentalhealth services.

Q. I'll come back to ask you about that staffingpoint that you've raised. Just in terms of sticking, Iguess, at the moment with the idea of cross-subsidisation,you say in your statement, and now I'm focusing on withinthe mental health budget, there is cross-subsidisationbetween our different mental health programs, and can youjust elaborate on that?A. Okay. So, working through our acute program, acuteand aged program, bed-based services, the EFT required forus to provide a quality and safe service within those areasis greater than the funding we receive for those services.

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The funding that we receive for our community healthcontact and all the other programs is there. If we areunable to recruit the EFT that we need to run thoseservices, that funding just by nature will offset theoverrun that I would have in my acute service.

And also, you might set a staffing profile in an acuteservice to manage the client load that you believe that youneed to have, but there's always going to be times when youget extremely complex clients entering in those services,and very often we will have to employ additional staffmembers to manage those more complex clients. And that'soften not in budget. I mean, you try and make an allowancefor that because you get an understanding on how often thatmight happen, but yeah, it's essentially unbudgeted fromthe funding coming in for those bed-based services.

Now, that same issue happens in physical health, soit's the same: you do a budget on a board, and you thinkthis is the staffing profile I'm going to need. If you geta patient or a client that needs more care and you need toprovide a safe environment, both for staff and for clients,then you would put on extra staffing.

Q. And so, if you could fill the positions that you haveavailable, you wouldn't be able to cross-subsidise in theway you've described and remain in budget?A. That's right.

Q. So then, there's a disincentive to be filling thosepositions, is there?A. Is there? There could be. I mean, I suppose atPeninsula Health we've got nowhere to put the additionalpeople at the moment, so we've got a physicalinfrastructure issue with our community programs at themoment. So, even if we were to recruit to the numbers thatwe think we need, we don't have anywhere to put them.

Q. There is difficulty in any event, partly because ofthe lack of infrastructure, in recruiting people?A. That's right, so that's not very attractive. Forexample, our Mornington Mental Health Community Team areresiding down at Rosebud. Now, it's very hard to recruitqualified mental health clinicians and say, come and workin Rosebud in a building that is less than adequate, andcan you look after clients up in Mornington. You know,

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it's just incredibly difficult for them and very difficultfor us to recruit into those vacancies.

Q. And they're based in Rosebud because there's nowhereelse for them to be?A. Yes, that's right, we've been looking at trying tofind an appropriate place to house that group.

Q. Can I take you now to ask you about the scope for you,or another public health service CEO, to be able toadvocate to DHHS for higher funding, and can you answerthat question in the context of your recent experience?A. So, this is probably my first year of advocating formental health services from a funding point of view. So,we met, we've done our budgets and we've been in regularcontact with the performance branch in the Department whohave been working with us on our budgets and targets.

We had our meeting last week to clarify a few thingsand to work through those budgets. Perhaps naively, Iasked, "When will we talk about the mental health budget?"And I was told that they don't control the mental healthbudget, the mental health budget is managed by the mentalhealth branch, and that it would be up to me to makecontact with the mental health branch to talk to them aboutthe mental health budget.

So, you know, I was quite surprised. I was shockedactually, and I thought, well, here we are trying to runthe whole budget: you know, it would be nice to be able totalk to people about our whole organisation, so I do needto go ahead and talk to the mental health branch about thebudget.

And that has been a problem. I've been the CEO for18 months. The last 12 months I've only had one formalmeeting with the mental health branch, and it's beensomewhat - or it has surprised me that there hasn't been alot of detail in those meetings about what's really goingon in our mental health service. So, you know, what arethe staffing deficits, what are the budget constraints,what are your quality and safety concerns, you know. Yeah,I was a bit surprised.

Q. How does that contrast with your interactions with theother branch, I don't recall what the name was?A. Yes, the performance and commission branch. They've

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got a lot more detail. I've met with them four times, sowe meet with them quarterly.

Q. That's four times over the past year?A. Twelve months, yeah. We have very much cleardiscussion around quality, safety. We talk about how we'regoing against our Statement of Priority KPIs, we talk aboutfunding, we talk about capital and infrastructure issues,so it is an opportunity to talk about the whole service,but you don't talk about mental health.

Now, I have requested for mental health to be in thoseconversations, and the last two meetings I've had a mentalhealth representative at those meetings.

Q. What have you been met with when you've tried toinclude it?A. So then, I'm just talking to the one person from themental health branch. So, the performance team - and Italk about this in my statement too, is that, it's hard -people don't understand what the mental health service isabout. It's kind of, even though we're sitting under theone building, and even though in the Department of Healthwe're sitting under - there's demarc - people just don'tseem to understand what the service is about, and thosedivides make it very difficult for people like me tounderstand what is required from a Chief Executive who'sresponsible for delivering mental health services.

Q. Can I take you now to ask you about systematicunderfunding in mental health, and I'm going to read to youa portion of a question we put to you when you werepreparing your statement, and this is at the top ofpage 12:

"The Commission understands that publichealth services are not funded for100 per cent of the cost of the servicesthey are expected to deliver (with theexpectation that the shortfall will be madeup from own-source revenue, includingprivate patient fees), and that theshortfall is larger for some services thanothers. For example, the Auditor-Generalfound that DHHS meets around 62 per cent ofthe cost of delivering an acute mentalhealth bed compared to 82 per cent of the

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cost of delivering an acute general bed."

We posed the question to you, what are theconsequences of a large discrepancy between costs ofservice delivery and the funding provided for a healthservice, and you've touched on some of those, but are thereothers that you'd seek to address at this point?A. I suppose the main areas are - is you're unable tomeet demand. Now, I don't know what the demand is in themental health service, except what's coming through theEmergency Departments, so I have no capability ofunderstanding of what is the unmet demand in the community.

So, kind of, our demand in the community is managed bythe number of resources that we have available. So, if youdon't have budget to recruit two EFT to provide thoseservices, then people miss out on those services. Or, ifyou don't have budget, then people miss out on thoseservices.

We would then not be able to achieve performancetargets, but there's not a huge number of performancetargets in the mental health service, so nobody's reallyprobably watching that.

And then it's from an infrastructure point of view, soit's difficult to - or our operational budgets don'tinclude capital infrastructure, so it's about negotiatingfor a capital budget is difficult.

Q. I'll come back to ask you about the capital investmenta bit later as well. In terms of, you mentioned justbriefly now in terms of the performance targets, thatthey're not really measured anyway. I want to ask youspecifically about the annual report of Peninsula Healthfor 2018 and the fact that it reported that it's exceedingKPIs in mental health, I think in every domain. So, that'sin relation to KPIs set by the Department?A. M'mm.

Q. And in your view, do they adequately measure theability for a service to meet demand?A. No.

Q. And, what about the ability to adequately measure theextent to which a full range of services are delivered tothe community?

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A. No, they don't monitor that.

Q. Do you have ideas about how those things could bebetter monitored?A. I think it would be helpful to know or get a sense ofwho in the community are not getting access to services.So, we have no sight of that. I don't know how many timesour clinicians are having to say "no" to people, or I don'tknow how often they say, "No, look, you're not complexenough." Our staff are often saying they feel as thoughthey're having to discharge people too quickly, so theremight be some indicators around those outcome measures.So, when is a good time to discharge somebody from aservice?

In physical health, you have the metrics, oh, they'renot in pain, they can get up and walk, they're eating food,they can shower themselves and manage their hygiene needs,so you've kind of got some metrics on how you can feelconfident that you're discharging somebody safely backhome. But we don't have those same measures, that I'maware of, in mental health, so maybe we could do somethinking around that.

I would like to understand what the unmet demand isand perhaps whether we're appropriately discharging peoplefrom our service. Then it would be useful also to know howwe're going and how we can compare ourselves to otherservices; so, are there best practice models in the systemthat we're unaware of, but I don't have any sight of thateither.

Q. Can I just ask you about funding growth in the pastthree years, just take you to that topic. One of thethings that you've mentioned in your statement is thatthere has been funding growth in the past three years?A. Absolutely.

Q. You haven't looked back further in terms of how thatcompares to the previous 10?A. No, that was very difficult for me to do in thetimeframe.

Q. But you would say nonetheless, even with this fundinggrowth in recent times, funding is insufficient forPeninsula Health to effectively provide the mental healthservices to meet the growing demand?

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A. So, the additional funding that we've received in thelast three years have been for specific programs of work,and so, they're very discrete pieces of funding. Forexample, $3.3 million this year, or last year going intothis year for a Crisis Hub in our Emergency Department.So, they're very specific pieces of work that we will do indeveloping a model of care and a budget, and recruit intothat new funding. So, that's where the majority havefunding over the last three years that I could ascertainhave been for the mental health services.

Q. Can I ask you then about capital investment or capitalfunding. One of the things you mention in your statementis that it's in mental health particularly difficult toattain. Can you just elaborate on that?A. So, again, this is from my limited experience of twohealth services, and I think what I can see is that theinvestment for big capital - so, this is some buildingcapital - relies on a good service plan, master plan andassessment of your facilities, and are often aligned toobvious indicators that are not being met: so EmergencyDepartments, theatres, acute beds.

We've been really fortunate at Peninsula Health: justin the last 12 months we've received $560 million to builda new Frankston Hospital, and now acute and aged mentalhealth services have been included in that.

I think, once we get beyond that acute system, it'sdifficult: I don't think it's understood what people aredoing in the community and where they're doing their workin the community. I mean, I must admit, I was quitesurprised, both at Barwon and at Peninsula when I toured tosee where our community services were working from, andthey're not great places, they're not in a great space atall; they're certainly not in an environment that wouldallow them to feel comfortably able to provide appropriateand effective care to the people that they're trying tooffer care to. It's always makeshift.

The Barwon acute facility was very poorly designed,and one of the things that I did in that three months waswork with that team on some redevelopment plans, but I'mnot too sure whether that actually progressed. They werehaving to staff - their staffing model to manage thatenvironment was very inefficient, but they needed to havemuch more additional staff because of the poor environment.

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Q. Just to touch on one of the issues you raised in youranswer: so you're talking about the lack of understandingof what community services need. Is that from aDepartmental level, is that what you're referring to?A. Yes, and probably from my level too. You know, untilyou go out there and actually see where they're working andhow they're trying to work, yeah, I was surprised.

Q. The final area I want to ask you about is the keyconstraints or pressures that may hamper the implementationof mental health reforms or service improvements. There'stwo in your statement that you address in particular, I'llask you about them individually.

The first is the lack of consistent and coherentstatewide model of care, and then insufficient integrationof mental health services. So, if we can start with thelack of consistent and coherent statewide model of care:you've talked about the model of care in the context ofPeninsula Health, but there's a broader picture?A. Yes. So to me, I don't think we do things in the sameway in each mental health service; well, it's not clear tome that we've got the same models.

Even in our own service, the experience of a clientcoming in to our Emergency Department and working throughour service could be very different for each individualperson that comes into our service. I'm not clear that thepeople that are coming into Peninsula Health are receivingthe same standard and the same level of best practice careand mental health services: I've got no way of seeing that,I've got no way of measuring that.

I kind of think, if somebody comes through in theEmergency Department with a physical health concern, I'vekind of got an understanding that a similar pathway forphysical health would be followed regardless of whetherthey came to Peninsula Health, Monash, The Alfred,Melbourne, it would be fairly similar. But I don't havethat confidence that we've got a similar process or modelin our mental health services.

Now, it could be my lack of understanding, but it'snot clear to me. It's not clear whether we're running aresidential program the same across the state; it's unclearto me about how we're running our community programs and

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whether we're providing the same models of care and supportin the community. I have no oversight of that.

So when it comes to talking about mental healthservices, if you don't understand it and have a languagefor it, then it's hard to describe to new staff members,it's hard to describe to Board members, and I cannotunderstand or see how a community member would be able tonavigate their way through the system. I have been in thesystem for a long time, I can navigate my way through thephysical health system; I don't think I'd be able tonavigate my way through the mental health service.

Q. And so why is it important that there's consistency inthe models of care across services or between services?A. I think it would be helpful, both in educating peopleabout mental health services and making them moreaccessible to people, and I also think it would help from abenchmarking and service provision. So both by trying tomeasure quality and outputs, outcome measures, and alsosome effectiveness measures to see whether the money we'reinvesting in our mental health services is beingeffectively used.

Q. Can I ask you then about what you say is insufficientintegration of mental health services?A. That's internally too, so again, the Barwon experienceand Peninsula experience. The acute mental healthservices, for example, are sitting on the same land mass,you know, are just there.

It feels to me like there is - I say it's a fear, andI don't know whether it's kind of a fear that I've had -but there's kind of a lack of confidence of being involvedwith the mental health team, because of that lack ofknowledge, that lack of understanding and that lack of -it's kind of like mental health service business. And so,I've had to work hard at being able to get in there andunderstand it, and that hasn't been easy.

And so, part of what we're trying to do at PeninsulaHealth is to have them better integrated into our wholeservice, so everybody understands what our mental healthservice is about, and to feel comfortable to be in thereand working with them. We've really engaged our mentalhealth team, we've got some great expertise, our clinicianshave got some fantastic knowledge, so we've been using our

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mental health team to come in and educate and support someof our other teams on how to manage difficult clients,dementia, behavioural concerns, et cetera, but it has beensomething that I've had to actively do. I've never beenencouraged, in all my roles as an Operational Director, toactively participate with mental health.

Q. Thank you, Ms Topp. Are there any matters you'd liketo cover that we haven't addressed?A. No, I think we've just about covered it all, thankyou.

MS COGHLAN: Chair, do the Commissioners have anyquestions?

COMMISSIONER COCKRAM: Q. Ms Topp, you've mentionedabout capital infrastructure particularly for communityservices. Can you just explain to the Commission howcommunity services are predominantly funded through theblock grant?A. Through the community contact hours. I don't know alot about the block grant, Alex. I know that we get ablock grant, but I think we get some amount of money tosupport some infrastructure. So, they've given us somemoney to rent an area in Frankston, but the issue is, isthat, we've had to rent not a purpose-built space for ourcommunity teams. So, we've kind of got not a greatbuilding that they're working out of, and it's certainlynot purpose-built for them to provide community services.

Q. Just then to continue on with what you just mentioned,is that, you have been supported by the Department forcovering the rental where Peninsula doesn't specificallyown the infrastructure that exists?A. That's right.

COMMISSIONER COCKRAM: Thank you.

CHAIR: Q. I just have a few issues that I'd like toraise. The first of them goes to, in your statement yougave a very useful analysis of the fact that the Statementof Priorities govern what's of interest and attention toyour Board and also to senior management, and you statedthat they are largely focused on physical health, accessand quality.

Can you just give us by way of comparison, what would

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go to the Board regularly for attention around physicalhealth and then I'd like to come back to the issue ofmental health?A. Some of the physical quality indicators that we wouldreport would be staph aureus blood infections, falls,pressure areas, any serious incidents that happen withinthe physical health services. I said "pressure areas",yeah.

Q. When you say "pressure areas", what does that mean?A. So, pressure areas are areas where a patient may havehad a graze or been in a bed for a long period of time andthey get a pressure sore.

Q. So they're indications of concerns about quality ofcare?A. Yeah, quality of care.

Q. And you'd report those sort of things to your Board ona regular basis in the dashboard reporting?A. That's right.

Q. What gets reported, if anything, to your Board on aregular basis about comparable events in mental health?A. None. So, not on a regular basis. If there was aserious incident, through our ISR reporting, we wouldreport, but there are no similar quality measures at themoment going up the Board regarding - in our PeninsulaHealth service.

Q. I think you've explained in part why that's the caseand the complexity and the lack of performance metrics thatyou think are helpful to drive that level ofaccountability.

But also in your witness statement you gave us a veryhelpful description of the range of mental health servicesthat are provided by Peninsula Health, both in acute andresidential settings and also in community settings, andit's quite an extensive list of services that are provided.

I guess it's about the visibility, you said, oncommunity mental health is also very limited to the Boardand senior management, notwithstanding the extensive natureof those services that are provided?A. That's exactly right. So, you really have to go outand ask the questions about the services that you provide,

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.25/07/2019 (18) J WILLIAMS (Ms Coghlan)


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and I've certainly spent the last 12 months going out andvisiting all those services so I can understand the servicethat they're providing and the environment that they'reproviding that service in.

Q. By way of comparison, you did say that the physicalhealth indicators and reporting framework's quitesophisticated, been established over a long period of time,and you engage in quite robust dialogue with the Departmentabout your performance. For how long has that sort ofrobust process, in your view, been in place in physicalhealth?A. A long time.

Q. Decades?A. Yes. Oh, 15 years, and they've certainly evolved. Inparticular, the quality measures have evolved.

Q. I think that's illustrative, in your view, of the factthat there's a long way to go in mental health until it hascomparable reporting?A. That's right.

CHAIR: Thank you very much.


MS COGHLAN: Thank you, Chair. It is early, but is now aconvenient time to break for lunch, given that the nextwitness will be attending at 1.30, and that's JenniferWilliams?

CHAIR: Thank you very much. Yes, we'll adjourn.

LUNCHEON ADJOURNMENT

UPON RESUMING AFTER LUNCH

MS COGHLAN: The next witness to be called is JenniferWilliams, and I call her now.

<JENNIFER JUNE WILLIAMS, affirmed and examined: [1.33pm]

MS COGHLAN: Q. Thank you Ms Williams. You've provideda statement to the Commission?A. I have.

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Q. I tender that statement. [WIT.0002.0020.0001] You arethe Chair of Northern Health?A. I am.

Q. Can you just outline for the Commissioners, firstly,just what your qualifications are?A. I've got a Bachelor of Economics and a Master ofScience and I'm a Fellow of the Institute of CompanyDirectors.

Q. You've had the role of Chair of Northern Healthsince July 2015?A. Correct.

Q. What about your current, other board appointments?A. I'm also the chair of Yooralla, and I'm on a number ofother boards: I'm on the Barwon Health Board, theInfoXchange Board, the Independent Hospital PricingAuthority, the Medical Research Advisory Board, I'm Chairof the Alfred Full-Time Medical Staff Trust, and I am justin the process of completing assistance to the SouthAustralian Government with the development of a mentalhealth plan as a panel member.

Q. Prior to those board appointments that you've justdescribed, you've had over 20 years of experience in thehealth sector?A. That's correct. I have, prior to my boardappointments which is just over three years ago, that Ihave moved to just do boards, I was the Chief Executive atthe Red Cross Blood Service for seven years, the ChiefExecutive at Alfred Health for five years, and the ChiefExecutive of Austin Health for seven years prior to that,and before that I was with the Department.

Q. And in fact, for 13 years, you had experience workingin the State Government of Victoria?A. I did, yes, that's correct.

Q. Just detail, just briefly, what those roles were?A. The final role I had was director, which is the deputysecretary level within the Department, they were the titlesused at the time. I was the Director of Aged Community andMental Health and, prior to that, I was the Director ofPsychiatric Services, and before that I was not in thehealth area, I was at the Department of Treasury andFinance, and worked in the area of information systems, and

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prior to that I was with the Ministry of Housing again, inthe area of information systems.

Q. Can I just ask you now to focus on providing some moredetail in relation to the professional roles that you'vehad in the mental health system in Victoria. Can I ask youto start with Barwon Health and your role as a board memberthere, at paragraph 15 of your statement.A. Yes. I was initially appointed as a delegate to theBoard at Barwon Health, they were having some financialissues at the time, and the office of ministerial delegateis often used to assist the health service to get out ofissues which are problematic. So, I started as aministerial delegate there and then I was appointed to theboard of Barwon Health, so subsequent to that I have been aboard member at Barwon Health and have continued to be so.

Q. Can I then also just ask you more specifically aboutyour time as Director of Psychiatric Services with theDepartment of Health and Community Services that you'vementioned, and just go into a bit more detail about yourresponsibilities in that role?A. Yes. As Director of Psychiatric Services, I wasresponsible for the mental health system for the state andmoving into that role initially the mental health serviceswere run by the state: so all the employees of mentalhealth reported to the Department, the accountabilitystructure, governance went back to the Department, not tohealth services, and part of my role there as runningmental health services was to bring about the mainstreamingof mental health and the de-institutionalisation and theestablishment of community-based services.

Q. Can I take you to that topic now, paragraph 44. Justdrawing on the experience that you've had, can you addressthe key factors that drove de-institutionalisation at thetime?A. Yes. There were a number of things that really causeda significant concern about what was happening with mentalhealth services. Just prior to my arrival there had beenthe disclosure of abuses of people with mental illness atinstitutions, so Lakeside was an example of that. Therewere also abuses of disabled people that were uncoveredduring that time. So, there was an intent by thegovernment, the Minister and the Director-General of theDepartment to change the model of care for mental healthand to adopt a de-institutionalisation model by moving the

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services from being directly run by the Department to beingmainstreamed and run by the public hospitals, and to at thesame time as relocating beds from the institution, toestablish community-based services that were also run bythe mainstream hospitals where the services would be movedto.

So, I was responsible for developing of policies andthe strategies to bring about those changes to seek thefunding to enable the funding of the services, whichincluded significant capital funds because new facilitiesneeded to be built in the acute hospitals, in the subacutehospitals, in residential care and the establishment ofcommunity clinics and the associated services like crisisteams, Mobile Support and Treatment teams for them tooperate in the community, as well as the establishment ofservices run by the NGOs for psychosocial rehab.

Q. You talked about one of the driving forces was whatwas being uncovered that was occurring within institutions,but there were two other things going on at that time,perhaps in the broader social setting, which was that therewas a real focus on homelessness, and there was also highlypublicised events where there'd been police shootings.Could you address those two areas?A. Yes, that made the problem much more acute and wasvery much in the public air. So, Brian Burdekin had done avery significant review of homelessness and that wasgetting a lot of coverage in the media and a lot ofinterest and attention politically, and that was uncoveringthat a very significant number of people that were homelesshad a mental illness, many of which had never receivedtreatment and that were unable to access treatment. So,that was certainly an impetus to drive the reforms inmental health.

And just a short time after the Burdekin reports werereleased, there were a very unfortunate series, not justone or two, but a series of police shootings where thepolice were put in situations of danger and the onlymeasures that they felt they could respond by was by usingfirearms, and there were both shootings that resulted indeath as well as other injuries to people with mentalillness, and of course, that received enormous attentionand concern in my area, in my Department and with theMinister, about what we could do to try and educate andtrain police in using other strategies to try and deal with

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people that were very agitated where police interventionwas obviously a safe thing to do, but to give them otheroptions as well as to train them in aspects of what mentalillness meant and developing strategies along with thepolice force about how they would deal with thosesituations.

Q. You have then just gone on to describe the wave ofreform and the things that were implemented. That wassupported by the national mental health plan which hadsimilar goals?A. Yes. Sorry?

Q. That was supported by the national mental health planwhich had similar goals?A. That is correct, so there are now five mental healthplans and this was the first of those. So, Victoria, aswith every other jurisdiction, needed to respond to thatnational plan, how was Victoria going to respond thatnational plan and how was it going to implement the goalsand the vision that were outlined in that plan.

So, that was the blueprint that really drove thedirection of the reform package in the area that I wasresponsible for, we developed it, and we developed thisdocument called the framework for mental health services inVictoria, that reflected those goals and identified how wewould achieve those and what we would implement to achievethe goals of that first plan.

Q. Can I just ask you about your observations in how thegovernment made the implementation of significant reformsto mental health services a key priority at that time?A. Yes, I think the circumstances of the issuesidentified in the institutions, the police shootings, theBurdekin report, those things certainly made mental healthvery visible and that it needed something done to it.

But we also had a secretary of the Department who wasvery determined to improve the plight of people with mentalillness. He himself had a disability and he was veryadamant that things needed to be changed and we neededquality services that protected the rights of people with amental illness in that they needed quality services. So aDirector-General who was very supportive, and a Ministerwho was also very receptive and supported the mental healthreforms.

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I have put in my statement that one of the thingswhich I think was very significant about what the Ministerdid, and it was Marie Tehan at the time, when she launchedour policy framework which was the policy, the blueprintfor reform, she took the speech we had prepared for her andtook it home and she actually wrote in that speech herselfthat, as Health Minister, she was prepared to be judged onwhat she did in the whole health portfolio on what she didin mental health alone. The weight of that commitmentcertainly sat on my shoulders and the people in theDepartment that I was working with to know that we had aMinister that was just so thoroughly committed to what wewere doing, that she would stand behind us and support whatwe were doing.

And that was done in a very real way because she wasable to deliver funding that we needed to bring about theimprovement in services, the addition of services, a verylarge capital program to address the construction of newfacilities, both in hospital and out of hospital.

So, that was obviously supported by the Premier andCabinet at the time, but I think the issues that we weredealing with in the community and that leadership and thatcommitment, that absolute dedication to making this work,was very much paramount in the success of what we were ableto do.

Q. One of the things you comment on in your statement isthat:

"Where there is a commitment at a seniorleadership level, proposals for mentalhealth reform and service improvement aremore likely to be presented to Cabinet andthe Expenditure Review Committee and aremore likely to be successful."

A. Yes, to have a Minister advocate so strongly for thisarea was vital to the success. The health portfolio is avery complex portfolio with enormous demands across manyareas, and mental health had never been a high priority interms of budget allocation, and I think that's somethingwhich hopefully this Royal Commission can contribute toputting it back as a high priority on the political agendato get that sort of attention.

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Because, it's not just the focus and the support, youneed that real support by budget allocation, because theenhancement of services cannot occur without additionalbudget.

Q. Do you think the vision and service system that wasput in place in the 1990s is still relevant to communityneeds?A. Yes, well that question does make me go back and thinkabout that question, and I think fundamentally, yes: whatwe put in place back there is still appropriate, and Ithink those of us that work in mental health can see thatthe system is still fundamentally there, but there havebeen many improvements and enhancements and innovations andnew parts of the service system that have been added intothe system since then, and a lot better reporting on what'sgoing on within mental health.

But things like the area based service, the inpatientacross child and adolescent, adult, aged, the forensicaspects, the special care needs of other specific groupsthat have particular needs, those elements are stillrelevant and are still very much in place today.

I think what has not happened though is that thedevelopment of the system has not kept up with the demand,and hence, the service system which was designed andperhaps served Victoria well for five or so years, neededto be continued to be built upon, expanded and evolved andthat has lagged the demand on the system, and hence,Victoria has lapsed back in terms of its leadership inmental health.

Q. Can I just now change direction and take you to yourrole as Chair of Northern Health, paragraph 9. Can I startby asking you about the arrangements under which MelbourneHealth provides clinical mental health services toNorthern?A. Yes. So, Northern Health does not run mental healthservices for the catchment that it serves, the broadcatchment that it serves. Some 20 years ago MelbourneHealth took responsibility for delivering the mental healthservices for the catchment that Northern Health covers aswell as the catchment that Western Health covers as well asMelbourne Health's own catchment, so it's responsible forthose three different services and the mental health

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services that they deliver.

And, it is Northern's view that this is a model thatworked well for many years, but for many years now it hasbeen a model that has needed to be changed and thatNorthern Health should take responsibility for the mentalhealth services that serve its catchment, and that thestaff that are working in those services that are currentlyemployed by Melbourne Health should be moved to NorthernHealth and that the management and the Board of NorthernHealth would take direct accountability for the mentalhealth services for its own population.

I would draw an analogy with other outsourced servicesto say that the mental health arrangements are quitedifferent from Northern Health simply purchasing mentalhealth services from Melbourne Health. It is not thatarrangement, so we purchase radiology services, we purchasefood, we purchase cleaning services, we have contracts, butthe Board is still accountable for the delivery of food andradiology and cleaning services.

In mental health the Board is not accountable orresponsible for the mental health services that areprovided, it is the Melbourne Health Board that isresponsible for that. So, we would very much like to seethat transition from Melbourne Health to Northern Health.There have been some discussions over some years for thatto occur, but there has been little progress in gettingabout that transfer.

Q. Could you just address some of the perhaps unintendedconsequences of that arrangement?A. Yes. There is almost no visibility of how funds areallocated, what the gaps might be, and what the issues arein mental health services because this is not informationthat comes either to the management or the Board ofNorthern Health, so we are pretty well blind to that.

But it is very difficult to disentangle mental healthfrom the other services that you provide within a hospitalas large and complex as Northern Health and its varioussites. So, the best example would be talking about mentalhealth patients that present to an Emergency Department,which is the responsibility of Northern Health, but whenthose patients present, we do not have access to the mentalhealth records of that patient if they had been receiving

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previous treatment, so we are not able to get informationabout previous treatment for those patients.

We're also reliant on Melbourne Health coming toassess and determine if those patients that might needadmission to a mental health bed, that we are dependent onMelbourne Health doing that. Northern Health can't dothat. The length of stay for mental health patients in theNorthern Health Emergency Department is veryunsatisfactory, there are extremely long waiting times forpatients in the Northern Health Emergency Departments.

Until only a couple of years ago we were getting noinformation at all about the performance of mental health,and we now do get a small number of indicators which onlyrelate to the performance within the Emergency Departmentof the services, and that looks at the waiting time formental health patients, and so, there are three indicatorsthat the Board now gets routinely but it is only restrictedto the Emergency Department part of the mental healthservices. We don't get any information about theperformance of mental health outside that.

Recently it came to the Board's attention that we wereconcerned that patients were being restrained for excessiveperiods of time in the Emergency Department. I wasobviously concerned about that and we asked if it waspossible to get information about numbers and duration andhow that might compare to other health services aboutrestraint in the Emergency Department, the implicationbeing that patients were being retrained because we didn'thave the appropriate facilities within the EmergencyDepartment for these patients. So, we now get some verylimited information on the restraint in the EmergencyDepartment but we don't have other information such asseclusion rates or re-admission rates, the normal sort ofindicators that other boards and other management teamswould get about the mental health services that run withintheir facilities.

Q. Can I perhaps draw on some of your previous experiencethen in asking the next phase of questions. This is on thetopic of prioritisation, paragraph 16. In thinking aboutyour past roles in particular, can you describe the extentto which you've seen the prioritisation of mental healthwithin the overall work of hospitals and services?A. Yes. So, at Northern Health, we do not put in

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submissions for additional funding for mental healthbecause, as I've just explained, we're not responsible forthat. But at other health services where I have worked,Barwon Health currently, The Alfred and the Austin whereI've been Chief Executive: so at those services you wouldhave regular dialogue with the Department about where yousaw there was a need for additional funding or for newservices to be funded, and then there's the annual budgetprocess where you can make specific submissions to getadditional funding for certain things.

So, certainly mental health would be considered bymanagement, and by the Board, about what submissions wouldbe made to government to attempt to get additional funding.For larger projects, which might be either operationalfunding or for larger capital projects, there would befull-blown business cases developed, with fully costed andbenefits and risks identified for those sorts of proposals.

So, that is an annual budget cycle and the mentalhealth part of those budget bids occurs alongside all otherbudget bids for all other parts of the health system.Within the Department it does get dealt with by a differentbit of the Department, but the process if you are sittingwithin a health service is the same when you're seekingadditional funding for surgery or medicine or for mentalhealth.

Q. Can we just take that a bit further then and addressthe process that involves DHHS, and specifically if I couldask you about the process for a health service advocatingat that level for additional funds?A. Yes. Well, the advocacy to the Department is vital sothat the Department understands that the needs and thepressures that you have - because all health services aremaking submissions to the Department and there's obviouslyprioritisation that has to occur to identify who is most inneed, because there are limits to the budget to be able toaddress all of the demands that come to them.

To support discussions with the Department, there areoften discussions with the Minister and the Minister'sOffice, and also you might involve local Members ofParliament to assist in talking to other Members ofParliament and/or the Minister to give additional supportto your budget needs.

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The mental health branch within the Department is theone that would need to support your budget bids for it toget even to the first level of consideration before theDepartment before those budget bids would even then get achance of being then presented to the Department ofTreasury for consideration in the overall budget.

Q. You've just raised there that there might be anattempt to engage with local government in terms of tryingto attract support and advocacy for your cause?A. Local government less so. I mean, it could be localgovernment, but typically it would be local Members ofParliament I was referring to.

Q. Sorry.A. At Federal or State level, yes. Because localgovernments provide some support to people with mentalillness, but they wouldn't typically support a budget bidto the State Government for extra resources.

Q. Just moving on then to your observations: what are thesources of unanticipated or greater than budgetedexpenditure within a hospital or health service both withinclinical mental health services and generally?A. The sources of?

Q. The sources of unanticipated --A. Unanticipated costs?

Q. Yes.A. In mental health, as with other areas, your budget isindexed by increases in labour costs usually that wouldcome out of an EBA agreement, so salaries would be indexedaccordingly, and then there is an adjustment for non-salaryincreases, the health CPI or CPI more generally, and yourbudget would get adjusted according to that.

There are usually efficiency dividends that arerequired each year, therefore savings that also would needto be made. So, while you might have an increase in costsresulting from those two areas, salary and non-salary thatI just mentioned, usually there is a gap that the healthservice usually has to try and fund or fund via reducingits costs to be able to operate within the parameters ofthe budget that has been provided.

So there would nearly every year, in my experience,

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you are required to look for efficiency savings so that youcan deliver a balanced budget.

Q. You mention in your statement that mental health hashistorically been seen as the poor cousin?A. Yes, it's a term often used in mental healthunfortunately, and it's sad that that term does get used,but people use it so commonly I think because they feelmental health misses out, where other areas within healthare addressed. So, the so-called sexy areas get funding,but mental health misses out, and that's why I'veemphasised in my statement the importance of having suchstrong support at very high levels right throughoutgovernment and the bureaucracy to try and redress, I think,that disadvantage that mental health has had over many,many years.

Q. Can you then please describe your observations as tothe quality, timeliness and depth of the performance andfinancial information available to the Board in relation toclinical mental health service delivery? Is that somethingyou can comment on particularly in terms of your previousexperience?A. Yes. I would say it's equivalent to other clinicalareas within a health service. Again, at Northern we don'thave that information but at other health services theywould have financial information about the Mental HealthProgram and they would have a series of other indicators toidentify trends within the existing health service andcomparisons with other health services across a range ofmetrics.

There are quite a large robust number of mental healthindicators which are published for the State as well asnational indicators. So, while a lot of these are notoutcome indicators, they are more input measures: like, howmany hours of community contacts and things like that,they're not really looking at what are the outcomes of thepatient. There are a lot of indicators where healthservices can compare themselves, and that is doneroutinely.

There is also organisations like the HealthRoundtable, that's a national organisation that givesinformation that enables you to compare things acrosshealth services, so you can look for where you need toimprove the care and give attention to the areas where

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there is under-performance compared with other areas.

Q. Does that apply to mental health in comparison?A. And that applies to mental health as well.

Q. On those sort of broader KPIs that you've identified?A. On those broader KPIs as well, yes.

Q. And so in your view and experience you would say thatyou don't think that mental health has suffered fromadverse internal prioritisation by boards?A. Not by boards, no, I don't think it does. I think inmy experience definitely the boards are focused on mentalhealth just as much as they are on other clinical areas andfrom time to time boards are very focused on mental healthbecause there are very serious incidents that occur inmental health, and the Board can get quite interested andconcerned about those issues.

I can think of one health service in particular wherethere were external reviews that showed a series of pooroutcomes where the Board established a sub-committee to doa deep dive and to monitor rectification of all of therecommendations that were made from a series of reviews.Sometimes those reviews are by the Chief Psychiatrist,sometimes they're external reviews which might have beencommissioned by the health service itself.

So, no, I don't think boards de-prioritise theimportance of mental health, certainly not in myexperience.

Q. Does it depend on the information the Board isprovided with?A. Certainly it does, but that goes for everything withingovernance: if management is not providing the Board theinformation, then it is not as easy for the Board toidentify what are the gaps, what are we not seeing, wheredo we have an interest? And boards might pick that upthemselves, but yes, you are very dependent on managementto making sure that they do give that balance and make surethat the mental health issues are presented to the Board asfrequently as necessary.

In things like the quality committees of the Board,that you're not just looking at the acute health andsubacute sort of issues, that you're also looking at all of

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the mental health issues as well, whether it be sentinelevents or root cause analysis of incidents, as well as someof the metrics that can identify how you're performingagainst other health services.

Q. Can I ask you now about geographic catchments and I amgoing to ask you whether you consider them to be helpful orunhelpful. You've got some particular experience in thefact that they were developed in the first place?A. Yes, I do. In fact, we established the catchmentconcept back in the early 90s when we developed the set ofreforms, and that was driven because there is a lot ofconcern that, when mental health patients present to aparticular hospital or service, that they would not receivetreatment, that they would be seen as too difficult, or thehospital would be too busy, or that they didn't have thecapacity to deal with the patient and the patient was lefthaving to go around the system trying to find someone thatwould assist them.

And so, for that reason area based mental health wereestablished to ensure that a patient had to be treated bythe health service within which they had a responsibilityfor that catchment area.

There has been criticism of it, that it removespatient choice, why can't patients drive across town andreceive services from another health service, and patientscan do that. That doesn't stop patients doing that, but itreally was the safety net to ensure that there would alwaysbe care for a mentally ill person that needed care and thata hospital cannot reject that care.

There are certainly difficulties with the boundariesand the defined catchment areas of mental health services,and there are currently certainly problems in child andadolescent and in other areas, I believe, in also in agedpsychiatry, that the boundaries don't line up to othercatchment areas, and I think a review of those catchmentareas to see if some changes could be made to betterline some of those catchments.

Whether you could now just through your contracts withhealth services ensure that they would be obligated alwaysto treat the mentally ill and therefore do away with thedefined, you know, I wouldn't rule that out, but it hasbeen seen as really a safety net for patients rather than

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something that was put up as a barrier for patients.

Q. You've talked about the proposal that Northern Healthtake control of mental health in the future. If that wasto be the case, how would you then optimise the governanceand accountability for mental health within your healthservice?A. Yes. Well, firstly we would need to be gazetted as ahospital that could receive mental health patients becausewe're not currently a gazetted hospital, since we don't dothat, so there is a requirement for government to giveassistance to that through regulation, I believe; it's nota legislative change that would be needed, so that would bethe first step that would need to happen.

The staff would need to be transferred across: thathas happened in other service areas, quite routinely thatcan be done. Northern Health would need an executivestructure to incorporate mental health as a significantclinical program reporting either to the Chief Executive orto the Chief Operating Officer, and there would need to bea transition program developed and negotiated withMelbourne Health to progressively bring the services acrossto the accountability of Northern Health.

It obviously would be at least a 12-month period totransition this across, and there would be some issues withsome of the services that would be more difficult totransition quickly than others; some that are entirelycatchment based are very easy, but there are others likechild and adolescent and things like that which would bemore complex to transition.

So, the Board would give a lot of attention to thetransition of mental health from Melbourne Health toNorthern Health.

I have raised this with the Chair of the Board atMelbourne Health and the Chief Executive at Northern hashad discussions with the Chief Executive at Melbourne andit is supported that this transition occurs, but we've justnot yet been able to progress the transition.

Q. In that sense, is it a bit premature to think abouthow governance and accountability for mental health mightbe optimised?A. We would certainly be giving a lot of attention to

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that, and the Mental Health Program would need to beincorporated within our governance frameworks, our clinicalgovernance frameworks, our audit program and a number ofdifferent aspects of the governance of Northern Healthwhere we currently do not have mental health at all.

Q. Can I ask you this question, really in terms of yourobservations of what's occurred since the 1990s, so sort ofgoing back to that historical perspective, at paragraph 53.

Since the 1990s have there been developments either inthe service system or in the community generally thatshould be considered in future reform? And you mightaddress in that activity-based funding but future reformideas more generally.A. Yes. Mental health has been funded historicallymainly through block funding, and there have been attemptsto come up with activity based funding models for mentalhealth over many years. You are probably going back15 years the work initially started on that.

That work has continued and there are now some datacollection occurring to move to a somewhat modified fundingsystem that the Independent Hospital Pricing Authority, onwhich I am on the Board, has been working with thejurisdictions to do it. So, I think Victoria is a willingparticipant in that, and I think in time that will probablyoccur with the support of other jurisdictions as well.

I think, since the 1990s, there have been - Imentioned before, we're now up to the Fifth National MentalHealth Plan and there have been multiple State plans aswell. What has been missing though is the determination toput these plans into action and for them to have successfulimplementation.

So, the goals and the visions within those plans arevery worthy, but we have not been able to realise theimprovements that those plans have aimed to achieve, and Igo again to the fact that budget support for those changesare necessary if mental health is to receive the attentionthat it does and if we are to start to deliver the sort ofquality mental health services that I think that everybodythat works in the sector would like to see delivered.

This goes right across the whole mental health system,and I think when you think about changes to the mental

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health system, you can't talk about improvements in justone component of it, because all parts of the mental healthsystem are so interrelated, so you could augment thebed-based services, but the community-based services wouldstill be under stress; the NGOs would still be under stressfor supported accommodation, et cetera.

So, there is so much interdependency with thedifferent components of the mental health system that thatis why I think the need for a plan that has got very firmcommitment at State level, at all levels, followed by thefunding, is essential if we are to move mental health outof being the lowest funded and one of the poorestperforming in the country, to be the pre-eminent State thatis leading in mental health service delivery where I thinkwe'd all like to see it.

MS COGHLAN: Thank you, Ms Williams. Chair, do theCommissioners have questions?

CHAIR: Q. I have a number. Thank you very much foryour overview today, Ms Williams.

I guess, trying to understand the particular modelthat's in place for Northern is unusual in terms of the wayit's constructed, so just to make sure I and the otherCommissioners understand it.

We had in the attachment and in the submission fromNorthern Health that your Emergency Department is one ofthe busiest, if not the busiest in the State?A. That's correct, Northern Health has more presentationsto its Emergency Department than any other hospital in theState, and we have more ambulance arrivals than any otherhospital in the State, and we've been the busiest for overa year now and we're growing at the rate of about8 per cent per annum, so again, the highest growth rate perannum and that's because of the population growth in thatnorthern corridor up the Hume Highway.

Q. Of those, I understand a significant number, manythousands present in any year with mental health issues anda proportion of those patients might need inpatientadmission?A. That's correct, yes.

Q. Can you make sure we understand what happens when your

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Emergency Department clinicians assess someone as needing amental health bed, for example?A. Okay. Well, the Northern Health clinicians can'tassess if someone needs a bed or not, we have to call onMelbourne Health to do that. So, if a mental healthpatient arrives at the Northern Emergency Department, theclinical staff there will make sure the patient ismedically stabilised, if it's an overdose patient,obviously they will treat that patient. But, if it's amental health assessment that's needed, that can only bedone by Melbourne Health, so we then call upon MelbourneHealth to attend the Emergency Department and to do amental health assessment of that patient, and then they arethe only ones who can make a decision on whether to admitor not.

We have acute mental health beds on site at Northernthat they are responsible for running. Often those bedsare full, and Melbourne Health might have to admit apatient from Northern Health to one of the other unitswithin Melbourne or within their own control, MelbourneHealth meaning Western Health or Melbourne Health. So,Melbourne Health makes those decisions, not NorthernHealth.

So unlike other patients, Northern Health emergencyphysicians can make the decision to admit a patient to amedical or surgical ward that will expedite the treatmentof those patients either to a short stay unit or up to oneof the wards to get treatment, but that does not occur withmental health patients at Northern.

Q. So, if there was, for example, an adverse event in theinpatient unit, i.e. a staff member assaulted by a patient,or vice versa, what visibility would your Board have ofthat incident?A. We'd have no visibility of any incidents that occur inthe mental health units at Northern Health. We havevisibility of assaults and other incidents that occur inthe Emergency Department and they are often jointly managedwith Melbourne Health and Northern Health if there isissues, incidents occurring within the EmergencyDepartment.

The Northern Health Emergency Department,unfortunately, is also very poorly configured to deal withmental health patients. We don't have a behavioural

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assessment unit which most hospitals now have, which is anarea that is specifically designed for mental healthpatients within the Emergency Department, so we have tocare for our mental health patients in our resuscitationbays where there could be severely unwell, frail old peopleor young people dealing with, it could be a verypsychotically disturbed mental health patient in thesebays, so we have also been attempting to get funding for abehavioural assessment unit so that we have betterfacilities within the Emergency Department to deal withthese patients.

Q. Can I just take it from that, that would also mean youwould not have visibility about how the triage arrangementswork, the activities of the CATT Team?A. Correct.

Q. The subacute services and community-based services inyour catchment area?A. No, we don't have visibility on that, no.

Q. On an unrelated matter but goes a little bit in termsof your background. In terms of thinking of a contemporarymental health system and in terms of technology, you didsay at the moment you don't have visibility about thatclient medical record. But in terms of other opportunitiesfor technology and enhancements in mental health, do youhave any views about what needs to be done to modernise themental health system in relation to technology?A. Not specifically in relation to technology. Access tothe medical record is a very easy thing. There is astatewide mental health IT system that's been in place formany, many years. It's just that, because we're not aprovider, we don't have access to that system, so not interms of technology.

I think the enhancements to mental health, the servicedelivery system, is more about trying to augment the sortof core elements of the mental health system, such as theinpatient beds and the community teams to have extendedservices. So, things like the behavioural assessment unitthat I mentioned before in the Emergency Department, theydidn't exist even five or six years ago and that has beensomething that's seen as a vast improvement of how we carefor people within the Emergency Department.

Things like urgent care centres, crisis centres which

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are in the community, certainly in South Australia that'ssomething that they are currently considering, it's been amodel that's been developed in the US where they haveclinical and non-clinical staff. There's a big peerworkforce that are used in these centres where police andambulance can take people to these centres so that theydon't present to an Emergency Department, and they are lesslike a clinical setting, and these are taking people thatdon't need to come to an Emergency Department and dealingwith them in these centres.

So, there are developments such as that which I thinkaugment the core service system which are very valuableadditions to what we have within our mental health system.

CHAIR: Thank you, we may follow up and make sure we knowwhere to look to get further information in relation tothat. Thank you.

MS COGHLAN: Thank you, Chair. May this witness beexcused?

CHAIR: Yes, thank you very much Ms Williams for yourstatement and your evidence today.


MS COGHLAN: Is now a convenient time for a five minutebreak?

CHAIR: Yes, a five minute break.

SHORT ADJOURNMENT

MS NICHOLS: Commissioners, the next witness is Ms KymPeake, I call her now.

<KYM LEE-ANNE PEAKE, affirmed and examined: [2.22pm]

MS NICHOLS: Q. Ms Peake, are you the Secretary of theDepartment of Health and Human Services?A. I am.

Q. You've held that role since November 2015?A. That's correct.

Q. Prior to holding that role, you had a number of senior

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1756

public service roles, including as Executive Director,Productivity and Inclusion at the Department of PrimeMinister and Cabinet?A. Yes.

Q. Deputy Secretary, Higher Education and Skills Group atthe Victorian Department of Education and Training?A. Yes.

Q. Lead Deputy Secretary, Strategy and Planning at theDepartment of Economic Development, Jobs, Transport andResources?A. That's right.

Q. And Deputy Secretary, Governance, Policy andCoordination at the Victorian Department of Premier andCabinet?A. That's right.

Q. Are you currently the President of the Institute ofPublic Administration Australia, Victorian branch?A. I am.

Q. With the help of the VGSO, have you prepared astatement?A. I have?

Q. I tender the statement. [WIT.0003.0006.1000]Ms Peake, I'd just like to ask you some questions, to startoff with, about the current state of the mental healthsystem in Victoria and confirm some things that are in yourstatement.

You've said that:

"Substantial reform is required to improvethe experience and outcomes of consumers ofmental health services in Victoria. Theintended shift to person-centred,rights-based and recovery-oriented servicemodels and practice has not yet beenrealised."

That's correct, isn't it?A. That is correct, and I think, if that's okay --

Q. Go ahead.

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A. I think the Premier and the Minister for MentalHealth, in announcing the Royal Commission, have reallypowerfully identified that we have a system that is notmeeting the needs of consumers and is not meeting theaspirations of the dedicated staff who support thoseconsumers, and I think the evidence that has been led tothe Royal Commission by incredibly brave people tellingtheir stories really underscores how critical anopportunity this Royal Commission is for us to do better inthe future.

Q. Thank you, Ms Peake. Can I just have you elaborate onthat. I'll just put to you what's in your statement tomake it efficient. You say this at paragraph 67 andfollowing:

"Melbourne's rapid demographic changes haveplaced particular pressure on services ingrowth corridors.

"This pressure within public mental healthservices is creating a vicious cycle. Alack of community-based care is increasingemergency presentations and driving a needfor more inpatient services - divertingresources from the community where carecould have been provided sooner and morecost-effectively. Pressure on inpatientunits is also driving shorter stays fortypical patients. Earlier discharge is inturn putting more pressure on communitymental health services, resulting in a'revolving door' of readmissions tohospital.

"While average lengths of stay in acuteinpatient units are decreasing, thereremain a significant number of long-staypatients in acute inpatient units who arenot discharged due to a lack of stablehousing or suitable sub-acute and non-acutebed-based alternatives.

"For people whose offending is related toan underlying mental illness, a gap in theavailability of treatment also risks peopleentering and becoming entrenched in the

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1758

justice system.

"There are also treatment gaps for childrenand young people, which mirror the gapsseen in the broader mental health system."

Does that encapsulate one of the core problems withinthe mental health system?A. I think it does, yes.

Q. Recently, the Chief Psychiatrist, who I note is heretoday, gave evidence in these terms:

"In response to high demand, mental healthservice providers focus on the most acuteand severely unwell consumers. Consumersmay receive less treatment and treatmentlater in an episode of illness oftenresulting in increased severity ofsymptoms. This compromises the principlesof Section 11 [of the Mental Health] Act ."

Now, you don't disagree with that, do you?A. I do not.

Q."This increases the likelihood of the needfor compulsory treatment. The numbers ofconsumers being treated compulsorilyrestricts the capacity of services toaccommodate individuals who seek treatmentvoluntarily."

You don't disagree with that either, do you?A. I do not.

Q. Finally, the Chief Psychiatrist also gave evidence inthese terms:

"Access to intensive treatment and supportmay only be available later in an episodeof illness and discharge is more likely tooccur before the therapeutic benefit of theadmission has been realised.Community-based services are then requiredto provide treatment to consumers in acutestages of illness."

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1759

You agree with that?A. I do.

Q. Finally:

"Community-based services have insufficientresources to provide the intensivetreatment and support required forconsumers who are very unwell. Theirresources do not allow them to provideevidence-based psychological interventionswhich assist with longer-term recovery.These consumers are therefore more likelyto experience slower recovery or a relapseof very acute symptoms."

You don't disagree with that, do you?A. I do not.

Q. Thank you. In the submissions filed by the VictorianGovernment, the government has pointed to five gaps in thesystem which I just want to take you to very briefly. Canwe have the slide from the submissions, please?[RES.0002.0005.0001]

Ms Peake, just take a moment to have a look at that.That's a page from the Victorian Government's submissions.Are you familiar with that page?A. I am, yes.

Q. You will see there that the gaps are identified. Thefirst, second and third run across the top, they are theearly engagement gap, the missing middle treatment gap, andthe severe mental illness treatment gap. Down the bottomis the child and young people treatment gap. You've saidquite a bit about those in your witness statement that Idon't think we need to elaborate on. That, if I may sayso, is consistent with the evidence we've heard in thisCommission: would you agree with that proposition?A. I would.

Q. Would you also agree that the gaps in treatment runright across the spectrum of people in Victoria who wouldbe seeking or would otherwise require treatment for mentalill-health?A. I would.

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Q. Can I ask you now about the box down the bottom whichgoes to the gaps in the foundation of the mental healthsystem, and those are named as: "Governance, FundingMechanisms, Data and Systems, Workforce andInfrastructure." The slide can be taken down now, thankyou.

In your statement and in the Victorian Governmentsubmissions, those factors are described as criticalenablers for the system. Can you say why they're describedin those terms?A. Yes. I think in any complex system the ways by whichthe policy funding and information settings are appliedreally influence how care is delivered, the capacity ofservices to be able to meet need, and the way in which asystem can continue to evolve and improve as evidencedevelops, but also as population shifts and the environmentwithin which those services are delivered changes.

Q. It is not possible to have a properly functioningsystem without each of those mechanisms itself properlyfunctioning, is it?A. I think that's right, and there will always be, Ithink, the case that each of those type of supportingconditions for a service system will need to evolve; thereisn't a perfect moment in any service system I've beeninvolved with where you would say all of those enablingconditions are at an optimum, but they are incrediblyimportant to continue to improve to deliver improvedoutcomes.

Q. Thank you. Can I just ask you to confirm the role ofthe Department, acknowledging that, as you've said in yourstatement, there are a number of other entities in thesystem that also play a role, I just want to concentrate onthe role of the Department, if I may.

You say this in your statement, under the heading,"The stewardship role of government", that:

"Making progress in improving the lives ofpeople facing complex social issuesrequires government to assume a duty ofcare and stewardship of the servicesdesigned to support them. How governmentexercises this role needs to be consistent

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1761

with the values-based principlesestablished for the whole reform."

A. That's correct.

Q. And that really, in some senses, encapsulates the roleof government in which the Department plays a part. Isthat right?A. That's right, and I think that really what I tried tocapture in the expression of stewardship and a duty ofcare, is that, we don't simply have a purchaser/providerrelationship with the entities that are co-producingoutcomes for people who have mental illness, for theirfamilies, for carers and for the staff involved; that wehave a responsibility and a very significant role inworking with consumer groups and with the providers ofservice to look at what are the best evidence and data toimprove the models of care, then to link that work on thedesign of models of care to the funding models that supportthose models of care to be delivered, through tounderstanding what sort of measures will enable us tounderstand the impact of those service models, but alsothat those service models are being appropriatelydelivered, right the way through then to the feedback loopsthat enable us to build new evidence and the cyclecontinues.

Q. Can I just, perhaps try and encapsulate what you'vejust said by reference to your statement. You say that:

"The Department fully accepts ourresponsibilities to perform a number ofcritical functions."

And to summarise them, they are the provisioning ofservice and infrastructure planning which involvesassessing need, comparing current services to need, thenidentifying gaps that might be priorities for investment?A. That's correct.

Q. Service model design and development, which involvesdrawing together leading evidence to design service modelsthat can meet the needs of identified consumers?A. In conjunction, as I mentioned, with the people whohave the expertise to inform that work.

Q. Yes:

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1762

"Resourcing involves the procurement orfunding of services, drawing on carefuldesign and specification of service modelsthat would meet need, and consideration ofhow these would be provided. Fundingmodels, prices and incentives are allconsiderations for resourcing."

A. That's right, and I think there are those two partsthat you've identified there: there is the case that wemake to government for a level of funding, and then withinthat available appropriation, it's the funding mechanismsthat optimise how that funding can be used.

Q."Performance monitoring is the means bywhich a commissioner [meaning the servicecommissioner of the Department] evaluateswhether funded services meet identifiedneed (including in specifications likequality). In modern public sectorcommissioning, performance monitoring isusually connected to improvement so thatservice systems do better over time."

I think I've covered those. Does that wellencapsulate the role of the Department?A. It does.

Q. We heard some evidence, some time ago now, fromAssistant Commissioner, Glenn Weir, and he said this tosay:

"I think everyone's worked really hard andnobly in our own particular areas to do thebest we can, but there's no high levelcoordination or leadership about a lot ofthese services being provided, and not onlyhow that service operates for theparticular silo, but how it works inintegrating with all the others.

"So, I think as an outcome, from ahealth-driven perspective to provide clearand concise direction around what is tryingto be achieved to help people experiencing

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1763

mental health and to prevent people whomight be at the risk of falling into theharm space to be done, that's really quiteclear: to provide high level, joined up,coordinated and integrated approaches towhat we're all doing for a common purpose,to reduce any barriers that might existbetween agencies, even between intraagency, I think that is absolutely vital.But if we keep doing the same thing andexpect a different outcome, I don't thinkthat's realistic."

Would you accept, Ms Peake, that a critical challengefor the Department is to provide leadership at a systemslevel?A. I would, but I would make two reflections.

Q. Yes.A. I would say that in my mind there are two levels ofgovernance that are really important to delivering whatthat witness was really pointing to. The first, as youreflect, is really at the system level, and I call thatinstitutional level of governance, and it is about the rolethat the Department plays in conjunction with the Ministryin providing that clarity of purpose, sense of directionand providing the mechanisms across government to reallyjoin up effort.

Secondly, there is then a service level governance,which is about how that then translates on the ground intobetter connected services, particularly for people who havemultiple or complex needs, and that doesn't happen simplyby there being appropriate policy settings and strongcollaboration across the Ministries that are involved insetting up the system settings. It is critical that thatcascades down into the institutions and agencies that areinvolved directly in the delivery of services and arereally best placed to understand the differing needs ofdiffering communities across the state.

Q. And it's the system leader's role, is it not, tounderstand how those values and objectives are understoodand cascading down throughout the entire system?A. It is.

Q. Can I turn now to a different topic, and I want to ask

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you about planning in order to meet demand. For thepurposes of these and a number of my questions I'm going toask you to put on a somewhat historical lens, acknowledgingthat you did not occupy the office you now hold for thewhole period, but we want to understand why it is some ofthe conditions we discussed before have arisen inorder that they don't arise in the future.

The evidence you acknowledged earlier points to a veryconsiderable and concerning gap between supply and demandin the mental health system: do you agree with that?A. I would just say before we go through this series ofquestions, that I will give answers as fully as I can,recognising that there may be public interest immunitymatters that come into scope, but I absolutely willendeavour to give you as much information as I can.

Q. Yes, Ms Peake, as your counsel and I have discussed Ithink the way we'll deal with this is, I'll ask you aquestion and you endeavour to answer the question as far asyou can. If you have any public interest immunity claim,just say so, and then we will take that off-line and we'llgo to the next question. Is that satisfactory?A. It is, and sorry, if you wouldn't mind repeating thefirst question?

Q. No problem. The evidence we discussed a moment agopoints to very considerable and concerning gaps betweensupply and demand in the mental health system: do you agreewith that?A. I would, and as we go through I would say that thequestions of supply are obviously influenced by resourcingdecisions by government.

Q. Of course.A. And so, there will be some limits on what I canreflect on there. I would also say that the ability of thesystem to respond to demand has, in Victoria, beenprofoundly affected by the rapid population growth, and Ithink we've heard from witnesses in the last day and a halfthe particular impacts that that has had in growthcorridors of the state, and not only in sheer numbers, butalso in changing demographics in those areas as well.

Q. With that said, I would like to focus on thecapabilities within the Department over time to engage withthat fact.

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As the Auditor-General observed in his Access Report,of which you have had notice, the Department's 10-Year Planfor 2009-2019, so the previous iteration of the plan,forecasts the imminent gap in meeting demand. Are youfamiliar with that report?A. With that plan, I am, yes.

Q. I would just like to turn to it, if I may. Can thedocument please be shown, it's entitled, "Because mentalhealth matters". You don't need to turn to it, Ms Peake,but I think it's referenced in paragraph 50 of yourstatement. The document will appear on the screen in justa moment. [DHHS.0002.0003.1073]

Before we turn to that document, can I just put thisto you. The Auditor-General said at p.10 of his AccessReport:

"As system manager, DHHS has aresponsibility to ensure service access bysupporting the foundations of the system:funding, capital infrastructure and servicedistribution, and understanding demand andsystem performance to guide properinvestment."

Do you accept that as an accurate description?A. I do, and as we work through this, how we build thatpicture, again, I think engages both level of governance:so, the system level governance and the sorts ofinformation systems that we have in part and need tocontinue to develop, but alongside that the rich localinformation that I think very positively has been acommitment through the Fifth National Mental Health Planfor stronger collaboration between Primary Health Networksand our health services to really pull together localinformation about need, which then will cascade up to giveus a richer - another source of rich information.

Q. I'll certainly give you an opportunity, Ms Peake, totalk a bit later on about the good work that's going onnow, but we might just go back in time a little bit, if wemay.

Commissioners, this document has hopefully appeared onyour screens. Can we go to internal page 7, please. Just

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to clarify, Ms Peake, you were not in the Department at thetime this document came out?A. I was not.

Q. But it's one you're reasonably familiar with, I takeit?A. I am.

Q. Just for context, about two-thirds of the way down thepage, you will see the words, "And yet". Can you see,nearing the top of the page:

"And yet, as Part One of this documentargues, it is time for a shift in ourthinking on mental health. This meanslooking at the mental health needs of thewhole of our population, at the socialdeterminants of mental health and mentalillness. It means considering mentalhealth and mental illness as everyone'sbusiness."

Now, that's just a bit of context. But we are doingthe very same thing right now, aren't we?A. That's right. This is very consistent with thephilosophy behind the stepped care model that is describedas a positive direction forward in the whole-of-governmentsubmission.

Q. Can we have internal page 9, please. You will see,under the heading:

"Secondly, it [this is the plan] coversprograms and services that respond topeople experiencing the spectrum of mentalhealth conditions."

I won't read out the whole text, but you will see thatthat plan is focused on covering the whole spectrum, andthat includes, does it not, the spectrum of people depictedin the graph that we displayed at the outset in theVictorian Government Solicitor's report?A. That's right, and I think the - sorry to leap ahead -but the practical consideration in that is the differentrole that the state will play in different parts of thesystem where some - your earlier description of our systemmanager and steward role is much more direct, and where

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we're talking about the work that is funded and regulatedby the Commonwealth Government, it is still incrediblyimportant that we are active partners and that that localand regional planning is brought to bear, but the leversthat we have to influence that are more indirect.

Q. But both this plan and current circumstances,including the Victorian Government submission, recognisethat the mental health system has to engage with the entirespectrum?A. That's right.

Q. And we've still got very significant gaps right acrossthe entire spectrum?A. That is absolutely right.

Q. Can we have internal page 13, please.A. I might just add, as we're moving to that, that for meone of the opportunities of being the Chair of theprincipal committee that brings together Commonwealth andstate senior officials responsible for mental health isabsolutely to make those connections, to look across thewhole system.

Q. Thank you, Ms Peake. Just while we're here we mightgo two-thirds of the way down the page. You will see thetext, the third dot point now from the bottom:

"Renew our Suicide Prevention Plan, NextSteps: Victoria's suicide prevention actionplan, using the new national framework tostrengthen our ability to identify andrespond to risk factors and emerging trendsin suicidal behaviour and suicideprevention."

I don't want to get into any great detail aboutsuicide, but are you familiar with whether the plan beingintroduced at that stage at Victoria's level wassubstantially different to the plan that's recently or morerelatively recently been rolled out?A. I'm not aware of the compatibility of those two, I'msorry.

Q. Thank you. Can we have internal page 14, please. Youwill see halfway down the page, under, "Reform area 3", thefirst dot point:

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"Create more accessible information, adviceand referral services that can assistpeople with a broad spectrum of mentalhealth problems, including a 24/7 callline for the general public."

Now, I'm not assuming you know about this, but do youhappen to know anything about that?A. Look, only that I know that there was, subsequent tothis strategy, a change in government and a change indirection on some of the detail of this plan, and I knowthat - I'm sure that we'll get to - there continue to besignificant challenges around triage in this state.

Q. Thank you, Ms Peake. Can we look at internal page 23,please. You will see under the heading, "Population basedplanning" the words:

"Planning services on the basis of theneeds of, and impacts on, the wholecommunity (and defined subgroups), andacross the spectrum of severity. Thisapproach will help ensure that the effortis invested where the greatest benefits canbe realised, while maintaining a clearfocus on those with the most intense andurgent needs for support ."

You would accept, wouldn't you, that that's the goalthat we have today, among others?A. That is correct.

Q. Can I ask for internal page 24, please. Under theheading, "The mental health outcomes framework" thedocument reads:

"In line with national health performanceframeworks the proposed mental healthoutcomes framework will provide the basisfor a set of agreed mental healthindicators ...

Population surveys and other data will beused to assess achievement over time ofagreed population outcomes, such asreductions in prevalence of mental health

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problems, level of disability associatedwith mental health problems and associatedeconomic and social impacts."

Q. This outcomes framework, is that really the kind ofoutcomes framework that you are now looking to implement?A. It is, and I'm happy to speak now or if you prefertill the end.

Q. We'll go to it at the end. But in substance, it isstill reasonably aspirational at this point?A. That's right, aspirational, narrative description ofoutcomes with key performance indicators, or performanceindicators that enable us to look at all parts of thesystem that need to contribute to improvement.

Q. We'll go to the substance of it a bit later, but mypoint is rather this: that way back in 2009 the objectiveto implement an outcomes framework was present. I acceptthat you weren't there at that time, but we're stillendeavouring to do that; is that right?A. I would caveat that in saying that the outcomesframework that was put in place with the 10-Year Plan thatwas released a couple of years ago does have a range ofmeasures that are now populated. There are still some thathave not been, but they have a range of indicators thathave been populated and are publicly released on an annualbasis.

Q. Can we go to internal page 29, please. Here you willsee the predictions that the Auditor-General referred to inhis Access Report. Under the heading, "Drivers forchange", it's said:

"An estimated 19 per cent of the populationis affected by a mental health problem inany 12-month period ...", and so on.

Underneath the box:

"In reality, by 2019 these numbers arelikely going to be higher given a range offactors including the ageing of thepopulation."

There's some further information, and it's then said:

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"Action is needed, not only to address thecurrent needs of the Victorian populationbut to plan for the projected numbers ofpeople likely to be seeking help for mentalhealth problems in 10 years' time. Noteveryone with a mental illness seeks amental health service, however those peoplewho actively seek a service, too many donot receive help due to factors includingcomplexity of needs, cost of accessingprivate services, or the lack of public orprivate services in their locality."

What I'd like to suggest, Ms Peake, is that, the needto understand the demand pressures caused by populationgrowth was understood back in 2009?A. Yeah, I think that's absolutely right, and thepopulation projections that were informed, the planning ofevery Department, so the whole-of-government populationprojections were wildly exceeded by the rapid growth in thestate; that doesn't detract from your point at all.

Secondly, I think that right around the world - andNew Zealand is a great example of this - the other piece ofthis puzzle is understanding the intersections betweenother services, whether that's housing, justice services,that also can either ameliorate or exacerbate thosepressuresQ. We'll come to those a bit later. Only two morereferences in this document. Can I have internal page 32,please. Under the heading, "Key aspects of the reformchallenge", it's said that:

"Despite progressive growth and manyinnovations in mental health-relatedservices over the past decade, somesignificant gaps and imbalances haveemerged. As a result, we are missingimportant opportunities to improve thelives of many Victorians ...

While strengthening core services remainsimportant, the wide consensus is that justinvesting in more of the same will notyield the benefits we need to see."

There's reference to a paper which focuses on a need

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for emphasis on:

"The importance of delivering services thatare recovery-oriented and are informed byconsumers' and carers' perspectives andrecognising the need for culture change toone that empowers those who use services."

Those values discussed there, they're now embodied inthe Mental Health Act and they're specifically reflected insection 11; is that right?A. That's correct.

Q. You are aware, are you not, that the ChiefPsychiatrist has given evidence to which I alluded brieflyearlier that essentially, because of very significantdemand pressures on the system, a number of thoseprinciples are being compromised and they're not able to beembodied in the mental health system?A. I think that's right, and I would also reinforce that,in my conversations with the Mental Health ComplaintsCommissioner, that the same feedback around the impact ofcapacity, models of care, and access has been on being ableto realise those principles.

Q. Finally, just on page 35, there is the observationthat:

"Demand pressures on specialist publicmental health services are considerable.Services have continued to provide qualitycare and made many adjustments to copeeffectively with demand. Yet measures suchas the rate of involuntary admissions, bedoccupancy levels, and emergency departmentwaits remain a cause for concern."

It's the case, isn't it, that it may have been aconcern at that point but it's now developed to a crisisstate?A. Yes, it really is at a much more serious level of bothoccupancy, and the ability for continuity of care into thecommunity is much more acute now even than then.

Q. Thank you, Ms Peake. I just want to put something toyou that the Auditor-General found, again acknowledgingthat you haven't been occupying the office for the whole

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period. The Auditor-General concluded in his Access Reportthat:

"The Department has done too little toaddress the imbalance between demand forand supply of mental health services inVictoria."

Now, the Department accepted that finding, did it not?A. It did, and again, I would reiterate that implicit inthat is both demand and supply, so we accept the finding inthe context of our capacity to work within the parameterswe operate within.

Q. Of course. There are many other subjects to discuss,but at a high level, what are your observations about thesystematic impediments to DHHS understanding, as a partwith others, addressing the gap between supply and demand?I'm asking you for an historical view at this stage?A. Yes, so I would talk to three impediments. The firstis that the clear issue around the level of resourcing thatis available to the system, and I think there are tworeasons for the pressure or the challenge that has beenencountered in securing those resources, and I think theseare actually common challenges to a lot of social services.

The first is technical, and it really goes to thepoints you've just made, the reflections of theAuditor-General around the sophistication of the systems,the analytic systems, to be able to model demand andprovide advice to government about social return oninvestment.

The second though I think is more cultural. When Ireflect, and I just look back at my time as Secretary ofDepartment of Health and Human Services, there really havebeen four areas that have experienced growth in funding,and they are: funding to support elective surgery andEmergency Department, funding to support mental healthactually, funding to support child protection and fundingto support family violence.

I think the common characteristic between those fourareas is that there's been strong political leadership,that there's been community acceptability for significantinvestment to be made in those areas, and there's been theability by the nature of the investment to show really

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reasonably quick outcomes or returns which build communitytrust in a service they value.

I do think that, where there is significant stigma anddiscrimination associated with a type of service, that thathas the practical effect of discounting the public valuethat is placed on that service.

And so, that would be my first reflection, that Ithink - I will be quick, I promise.

Q. Yes, we'll return to that question later.A. The funding is a critical one. The second one, andI'm sure we'll return to this so I'll just give a headline,is around the funding mechanisms. We have had an expertview that really elucidates the ways in which the existingblock funding model, as you've heard a lot of evidenceabout, doesn't create the right incentives for the rightmodels of care and continuity of care, and we can talk moreabout the history of that.

Then I think the third is that there hasn't been thelink between the population level data that we holdtranslating down or, sorry, gathering up more localinformation, we haven't had good enough systems for that.

Q. Thank you, Ms Peake, that's a very convenient summary.Just on that point, without descending to too muchgranularity, one of the foundation gaps you identify, orthe government identifies, and the Auditor-Generalidentified, is data limitations, and I think it's called anundeveloped or unrefined approach to data forecasting inthe Victorian Government's submissions.

Can you say, without being too technical about it,what are the principal limitations on data gathering?A. So, a couple: one is the information systems to enabledata that is captured routinely to be conveniently,quickly, easily, aggregated up.

The second then is that, the methods that we have usedin government have tended to take more of a statisticalapproach to the analysis of that data.

Q. As opposed to?A. As opposed to really being able to use moresophisticated machine learning techniques to be able to

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project forward and in different scenarios - it's calledmicro-simulation, I won't get technical - but to reallyunderstand what would be the practical effect of differenttypes of investment on costs and outcomes.

Q. Is there presently the capability to do that?A. We are developing that capability. We have muchbetter systems to be able to do the machine learning; themicro-simulation, we are in the process of - even thoughwe're in Australia, it's got this deep capability, butwe're in the process of building that capability right now.

Q. Can I just interrogate that answer a little bitbecause, implicit in it, it may not have been intentional,is the suggestion, I think, that you don't have the datacapability because technically it's not available. WhatI'm really after is, what were the impediments to gatheringand analysing the appropriate data?A. That was really the first piece. The gathering wasreally that we haven't had the information systems on theground to make it easy to extract that data. I know theAuditor-General talked at some length about the differencebetween our model of governance of health services wherethere are individual systems at each health service. Thereare many benefits to that, and I'm sure we'll talk aboutthat. One of the practical implications is that, with afew exceptions we don't have an easy way of looking in andseeing data across the board, and then there's thetechnical capability to analyse it.

Q. But you would accept, wouldn't you, that it'sessential to have that capability to gather data from thecomponent parts of the system that has devolved governance?A. And, in order to do that, you either need to have, andthere have been efforts to do this, you either need to havecompatible systems, and that's really not realistic, or youneed to get - the IT market is getting much better atproviding solutions where you can have data kind of suckedout and put into a portal - and I am not trying to makeexcuses for the gaps in our capabilities, but I think thereis much more technical ability to, in a cost-effective way,fulfil that requirement of our system management with thedevelopments in the cloud and IT systems going forward.

Q. There is the suggestion, is there, that the reasonthere hasn't been proper data gathering and analysis hasbeen simply because of a lack of existing technology?

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A. No, but in the absence of that technology, there hasbeen a much bigger endeavour, and I have also indicated, Ithink, it's not only about that sucking up the data, it hasbeen about the analytical capability to make use of thatdata as well.

Q. To finish off that point, your evidence is that theDepartment is --A. On the journey.

Q. -- gaining capability?A. On the journey.

Q. And, to put it --A. Sorry, and I should say that I think one of the reallyimportant developments in the last couple of years on theback of the Duckett review into quality and safety in thehealth system has been the creation of the Victorian HealthInformation Agency which has provided a dedicatedcapability in the Department for this type of work, workingwith our performance people to make sure that we've gotboth the custodianship of data clear, but then the analysisof that data capabilities being lifted.

Q. Alright, acknowledging that today's not the occasionto focus at great length on data, but you do accept, don'tyou, that in light of what the Auditor-General has found,and in light of the various statements in your evidence inthe Victorian Government's submissions, that having thecapacity to gather and properly analyse data is absolutelyessential for the system leader?A. It is a critical priority and it is one that is notfully there in the system, absolutely.

Q. And what you said in your submissions is that theabsence of data capacity, if I can just summarise it inthat way, has inhibited long-term statewide infrastructureplanning: that's correct, isn't it?A. It has, as well as service planning, yes.

Q. And it's also inhibited outcomes monitoring?A. It has, although I would add, in addition to thosecore data sources, I think that we have been - between 2010and now, evolving our technical capability about definingthe indicators as well.

Q. Alright, but I think your evidence --

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A. But it is a critical part of it, yes.

Q. And your evidence and the Victorian Government'ssubmissions are to the effect that the data problems haveinhibited outcomes monitoring?A. Yes.

Q. And also have inhibited demand predictions for thepurposes of managing supply?A. Correct.

Q. You accept, don't you, I think on behalf of yourpredecessors, that back in 2009 it must have beenunderstood that this sort of capability would be necessaryto have?A. And would be a priority to develop, yes.

Q. And it now is a priority, I take it?A. And it has - there has been improvements; there's away to go.

Q. Alright, we'll leave that topic for now. With thatbackground, can you say, why is it that, at least on theevidence we've heard in this Commission, that Victoria'sgrowth corridors have experienced the highest rates ofpopulation growth, are said to have some of the highestrates of mental distress, but also received some of thelowest rates of funding per capita? What factors have ledto that outcome?A. So, I think there's really two factors: one is thelead times for the development of infrastructure andcreation of bed capacity and adding staff. There have beenrecent investments in the last couple of years, they willtake a while to come online. So, in the meantime wherethere is extra funding that is provided to us, the way inwhich we allocate that money takes account of where thereis capacity to deliver.

Q. So, are you saying that --A. It's a bit of a vicious cycle.

Q. -- it's hard to catch up: if population growth getsaway from you, it's quite hard to catch up, is that thegist of it?A. That's right, and to make sure that we make best useof the money right now, that it is dispersed differentlybetween the catchments.

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Q. Does the Department accept that it is a priority amongmany others, but a priority nonetheless to ensure that thegrowth corridors are better funded?A. Better funded, and that there is an opportunity tolook at what that funding is used for, so the models ofcare.

Q. Can I ask you about the framework for strategicplanning. Now, the 10-Year Mental Health Plan is the mostimportant strategic document, is it not?A. Unlike the 2009 document, we were very conscious -this was right at the time I started - but we were veryconscious of not looking to start/stop strategic direction.In the 10-Year Plan there is a cross-reference back tobuilding on the strategy from 2009. I think there was avery strong view that, to take another three years, whichwas about the time that strategic plan took to develop,would miss the urgency of getting on with ensuring thatthere was more capacity put into the system.

Q. But it is the document that sets out the strategic --A. If I could just finish.

Q. Oh, sorry.A. So, therefore, it was a clear decision that it wouldbe an important document, but not the only document, thatwould guide strategic direction and investment in that termof government, and that it would be complemented with someother sub-plans or parallel work on a service andinfrastructure plan for the whole of health, includingmental health, for example, a Suicide Prevention Plan whichwas released about a year later; the work that washappening at the time on the Fifth National Mental HealthPlan, putting effort into that and the regional planningthat came out of - that was reflected as a commitment, allMinisters signed on to from that.

So, I think it is important to say it was an importantdocument, but it was designed in a slightly more narrow wayto enable us as a Department and the government morebroadly to get on with the important work of the system.

Q. So, acknowledging that there are companion pieces,this nevertheless is the place where one looks to find thestrategic plan for mental health in Victoria?A. Certainly, it is the place to look for the outcomes.

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Again, I would say that there are a suite of documents thatgive you the strategic plan.

Q. In your statement you've said the plan was a goodstart to defining outcomes, but that further work isneeded. I'll take you very shortly to it, so you can tellus what that work is. But, I think in light of somefindings of the Auditor-General, in your statement you'veacknowledged that the plan did not outline the optimallevel and mix of public mental health services or describeactions required to deliver a comprehensive stepped caremodel for Victoria?A. That's right, because it was part of a suite ofdocuments that covered different elements of that.

Q. I see. Do you accept the Auditor-General's findingthat, while the 10-Year Plan clearly identified significantservice demand and access issues, little within it directlyaddresses the access issues?A. And again, I think the intent was that that work wouldbe progressed outside of the domain of the plan through thedevelopment of a service and infrastructure plan, andthrough then subsequently some commissioned work that did amuch deeper dive on looking at what were the drivers andsolutions which is informing continued thinking in theDepartment.

Q. We'll go to more present time in a moment, but do youaccept the Auditor-General's criticism really of the plan,that it really didn't deal itself with the most pressingissue, which was the access to services issue?A. I would absolutely accept the finding about the scopeof the plan. I guess what I am trying to indicate, isthat, my perspective coming into the Department at thatpoint was that that wasn't the intent of the plan. Theintent of the plan was to provide what over that term ofgovernment in particular could be the initial work, thefirst two waves of reform, to enable there to be a deeperdive into those issues around access and forward solutions,and the third wave of the plan foreshadowed that furtherwork being done, it didn't try and wait for it to be donefor the plan to be released.

Q. Do you accept that, as a system leader going forward,that the strategic vision and documents that reflect thatshould deal with pressing issues such as access?A. Absolutely, and that the link then to the 10-Year Plan

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needs to be made very clear, where you have a separatedocument that provides that sort of guidance to the sector.

And, with the advent of the Royal Commission I wouldbe extremely optimistic that the findings andrecommendations of the Royal Commission will provide uswith a lot of that roadmap which may lead to there needingto be some or some significant changes to the overarchingplan, but obviously will provide more detailed guidance onthose specific issues around access as well.

Q. Of course, and just one more question on this topic:back in 2015, when that plan was introduced - is that theright date?A. Yes, it was the end of - it was November 2015.

Q. So at that point a detailed dive on access hadn'toccurred. When was the first time that that occurred?A. Yes, so there was a significant piece of work that wasundertaken in, I think it was the second half of 2016 into2017.

Q. Thank you. Can I just ask you some questions abouttargets. You've given some evidence in your statement thatyou think there are some difficulties with targets incomplex service systems, and that's at paragraph 165 ofyour statement.

I think, to be fair, I think you distinguished betweentargets and aspirational or qualitative expressions ofoutcome measures.A. That's right.

Q. The Auditor-General gave some evidence this morningthat, reflecting on his analysis of the 10-Year Plan, thereought to be targets in such documents however they exist.His evidence was to this effect: that you have, as systemleader, the capacity to mitigate the risks of problems withtargets by properly defining them. What do you say aboutthat?A. Yeah, thank you. Because it is a really importantquestion and it's one of very few points of slightlydifferent perspective that, as a system manager, I thinkthat I bring. There is absolutely much in theAuditor-General's report that I welcome and agree with butthis is a point of fine difference.

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From my perspective, I think that it is reallyimportant that an outcomes framework provides the means ofmeasuring across the range of parts of the system, so theparts of the stepped care system, the range ofinterventions that are going to be necessary to achieveimprovements.

The great risk with leaping to numeric targets when wedon't have the underlying data foundations, is thatactually perversely we might further entrench stigma anddiscrimination - or discrimination; that we mightinadvertently lead to there being incentive created to onlyserve the service, the clients with less complex needs, andthat there can perversely be situations that I'veabsolutely seen in other service systems, where there isover-emphasis on one part of the system at the expense ofadvancing reform in other parts of the system.

That's really I think been evident in the UK where anover-emphasis on, in fact some access targets, has reallyresulted in quality and safety issues in the system. Icould use the example of how important it is, when we thinkabout sentinel events, that we don't inadvertently create,through a target, a perverse distortion of behaviour not tospeak up and report adverse events.

So, there are times when numeric targets are entirelyappropriate, but I think numeric targets tend to be moreappropriate where the data is robust and well-established,where there is clear attribution between an action and aresult, and generally where there is a more straightforwardset of actions that need to be taken that involve fewerparties than when we're talking about all of the actorsinvolved in a stepped care model being put in place.

Q. Do you accept the Auditor-General's point though, thatthere needs to be a means, in an outcomes framework, ofmeasuring the difference between where you are now --A. Yes.

Q. Sorry, where you were: where you are now and whereyou're intending to get to?A. Well, certainly the first two, and I think you mighthave had some evidence a few days ago from the Road SafetyAuthority as well around the benefits of having anaspirational target like Towards Zero, and the realcriticality of measuring as you go on progress and having a

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suite of measures that enable you to do that. So, I thinkthat is incredibly important, and the Mental Health AnnualReport, is our intent, to be able to make that informationnot only internally obvious but publicly reported.

And so, having an aspirational target of where youwant to get to I'm entirely comfortable with. Where I getuncomfortable is, if it is reduced by this amount to thatamount for only a few of the important outcomes that aregoing to drive a systemic complex reform.

Q. But that would speak to having to design your targetsproperty, wouldn't it?A. No, because I think that would mean either you have somany targets that cover all facets of the reform that youblunt their impact, because actually targets are generallymost powerful when there are few of them that really dodirect effort, and that for me feels to be in conflict withsaying, across a stepped care system there are multiple -your earlier point about there being multiple parts of thesystem involving a broad array of actors that need to beinvolved in delivering better service and better outcomes.

Q. Alright, but you're not suggesting, are you, that themeasures in the appendix to the Mental Health Annual Reportcan't be improved?A. Not at all, and I think that's clear and I've madethat point in my witness statement, that one of the - andin the whole-of-government submission - that based on theevidence and the analysis, that the Royal Commission doesreally welcome that view, that insight on how thosemeasures can be improved.

We're doing a lot of work right now with educationabout how the educational measures can be enhanced andpopulated, and so, absolutely it's a work-in-progress.

Q. Just back on the question of access, theAuditor-General has suggested that measures for wait timesfor services and the number of consumers declined ordelayed services due to capacity constraints, and consumerreported experience of service accessibility would all beuseful measures in relation to access: do you accept that?A. Yeah, so again, two points very quickly that I wouldmake: one is that, at the moment I think that we have dataand indicators around access that are spread between toomany different data collections and reporting tools. So,

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we have quarterly reporting, we have Statement of Priorityreporting, we have the reporting associated with the10-Year Mental Health Plan which is more outcome-oriented,and we have other sort of episodic reporting that is used.

In turning to 2018/19 we received some funding tocomplement the outcomes framework with a performancemanagement framework which really goes more to systemperformance and access issues.

Having said all of that, I do agree that, as wedevelop that performance management framework, which Ithink is the right place for these type of access measures,I think the Auditor-General's reflections, particularly inrelation to where people have contacted a triage serviceand then not received a service and then subsequentlypresented to an Emergency Department and/or been admitted,are really critical information for us to have a betterhandle on.

Q. Thank you. Just finally on the 10-Year Plan, theAuditor-General said that there was a lack of routinesenior level oversight of and reporting against the plan:you accept that finding?A. One of the things I would reflect, and you may come tothis a bit later, about the capabilities that are needed tobe developed, but a system process and capability or skilllevel has been developing that sort of project managementcapability.

We do have governance structures within theDepartment. The 10-Year Plan is reported up through to asub-committee of the Executive Board that I Chair, butcertainly I think the reflections of the Auditor-Generaland the Implementation Monitor for Family Violence havegiven us pause in the last 12 months to think about bothhow those governance arrangements are working and also thesystems and tools that are necessary, and we are developingan IT platform called Our Impact which will make thatreporting more standard and enable there to be morescrutiny.

Q. To the extent you can say, is there any capability theDepartment needs to develop in relation to personnel inthat respect or is it more of an IT issue?A. I think there is a project management discipline, orcapability that is in short supply through the public

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service, and there are targeted - you know, there'stargeted work we're doing as a Department but I think thereis more that we need to do to build the skills in how youbreak down complex reform into actionable deliverables, aswell as then have the systems to monitor progress.

Q. I just note for completeness, Ms Peake, we won't go toit in the interests of time, but there are in your witnessstatement set out a number of the activities and verysignificant resources that have been devoted to undertakingthe activities in the 10-Year Plan; I've been directing myquestions more to the management and implementation andmonitoring of it.

Can I ask you now about a different question, and thatis the issue of trials and what I mean by that is programsbeing rolled out on a trial or pilot basis. There has beena significant amount of evidence in this Commission from arange of people to the effect that, when good programs arerolled out as a trial and then their funding becomesuncertain and their continuity becomes uncertain, a wholerange of problems occur, including that staff who have beensecured and are working well may not be able to be secured;consumers lose continuity and lose relationships.

Do you accept that one consequence of having too manypilots is instability in the system.A. So, what I would say is that I think historically thepilots have been used not only to trial innovation, butalso to enable there to be partial implementation withinbudget capacity. I think that conflation of using trialsfor an innovation purpose, versus partial implementationhas created the effect that you describe.

I think as a whole-of-government there has been a lotof work done in the last couple of years to be really clearabout innovation methodology, what sort of analytics andperformance measurement and evaluation is important, andwhat sort of decision-making processes are necessary toenable there to be a genuine trial of innovation,evaluation of impact and then approach to scaling. So, Ithink again it's something where a historical view versus aforward-looking approach is a bit different.

Q. And your forward-looking approach is to try andengender longevity in funding and program continuity; isthat right?

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A. Where it is evidence-based and --

Q. Of course.A. -- and where there is evidence of working. I wouldnever want to be saying that there is no space for genuineinnovation and trialling, and also that it is important, ifwe are going to have more innovation in the system, thatit's okay for some things to not work and therefore --

Q. Of course.A. -- absolutely to call quits on something that hasn'tachieved its intended aim.

Q. On the question of catchments, the VictorianGovernment's submissions state that:

"Misaligned catchment boundaries arepreventing people from accessing services."

We've certainly heard evidence to that effect in theCommission, and I'll take you in a moment to your viewsabout catchments briefly, but can I ask you this first: theAuditor-General said in his Access Report in relation tothe Department:

"Despite understanding these issues formany years [that's issues about catchmentsand access] and commissioning work toexamine them and make recommendations, theDepartment did not take action to addressthem."

Did you accept that finding?A. And it will come to the later discussion about what wemean by catchments. So, we accepted the finding and Ithink there are many layers to the geographic boundaryversus the operational management within a catchment, and Iknow the previous witness talked to some of the operationalgovernance issues that are relevant to catchments as well,but there is no question that there is a significant needand opportunity, both through the Royal Commission andpotentially in parallel with the Royal Commission, to dealwith some of those challenges around catchments withoutabandoning the concept altogether.Q. The purpose of my question was really to elicitwhether there is any structural or systematic impediment tonot being able to implement reform catchment, acknowledging

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like most things in mental health it's complex. Justresponding to the Auditor-General's finding about the factthat the issue was understood for a long time and not actedon?A. I think the two things I would say with impedimentswas, firstly, that there wasn't an effective way for jointwork with PHNs or with the primary care system to reallybring together the thinking about catchments. Andsecondly, that the timing of decision-making often got outof synch with the rhythm of an election cycle, for want ofbetter words, and so, opportunities have been missed.

Q. Just picking up on that observation as a generalpoint, the timing of reform measures and their coincidingor not with election cycles: is that a problem thatbedevils someone trying to enact reform in a system?A. So, I wouldn't cast it in the language of "it's aproblem". I would say it's a really important factor totake into account in thinking about the sequencing and paceof both advice to government and implementation.

Q. We'll come to those at the end, we'll be asking yourviews about those things. Can I ask you a bit more aboutcapital infrastructure. You've acknowledged the role ofthe Department in commissioning system-wide service andinfrastructure and planning, and we've dealt with the issueof the data limitations.

There's a relationship drawn in the submissions of theVictorian Government about the limitations on data andbeing able to engage in commissioning infrastructure formental health: what's the relationship between the two?A. Well, it's really the comment that I made earlier,that in the absence of sufficient physical capacity itbecomes a challenge to actually then allocate money forservices in places that they are needed because there isn'tthe staff or the physical space.

Q. I see, alright. Separately, the Commission has heardevidence that Victoria has a serious shortage of acuteinpatient beds, and one of the lowest bed bases nationally,and also, that many inpatient facilities don't provideappropriate, safe or therapeutic environments. I know it'sa very broad question, but what in your view are the keyfactors that have led to that outcome?A. So, I think it is important to say that thecomparisons nationally are not altogether helpful because

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Victoria, right from the start of - or the model that wasimplemented post de-institutionalisation has really putsignificant emphasis on the community model which is againrecommended through the government, or proposed through thegovernment submission for further investigation.

That was really because there was a strong view thattherapeutic settings are more amenable to a communityenvironment, and that is not to discount the importance ofhaving acute inpatient capacity for people who are severelyunwell, but their ongoing treatment and recovery and thenrehabilitation, I think there is significant evidence thatwe need to think about those two things differently andthat's part of the stepped care model.

So, having said that as a bit of a caveat, I thinkthat it goes back in part to my earlier comment about theway in which funding deliberations are influenced by thosethree factors of: political leadership, communityacceptability and the ability to implement quickly to buildconfidence in a service the community values.

We have seen in the most recent couple of budgets moreinvestment put in to inpatient beds, and we have a long wayto go.

Q. So, is the gist of your answer, that it hasn't,politically speaking, been able to be prioritised in thepast?A. I think that is definitely a part of it, the competingneed for there to be also investment in the communitysector which is seen as a really critical part of thesystem, and then comes back again to the lead time in termsof infrastructure constraints.

Q. I see, thank you. Does the Department have a detailedinfrastructure plan for mental health services?A. And this is going to be into a space where I can giveyou a partial answer.

Q. Go as far as you can.A. So, we have been doing a lot of work in the lastfew years with the creation of the Health and HumanServices Building Authority to build the analytical base sothat we can provide effective advice into the annual budgetcycle. That's probably as far as I can go.

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Q. So, you can't tell us any more because?A. So, certainly that --

Q. Just to be clear about why you can't answer any moreabout that topic?A. It really does move into a matter of public interestimmunity about the extent of the planning.

Q. Alright, we won't pursue that any longer for the timebeing, but we will note that that question has been askedand you've answered it as far as you can for the moment.

You've mentioned the Victorian Health and HumanServices Building Authority in your statement, and you'vesaid that:

"There is an increasing focus onincorporating and prioritising mentalhealth service provision."

What's new about that?A. Yeah, so one of the things that we have been reallydoing more of since 2016 is re-integrating mental healthresponsibilities into the broader health stewardshipresponsibilities of the Department.

The rationale for that is both that, I do think thatmental health should be considered a specialty like anyother in the health system, I think that's important, toimprove the parity between physical and mental health andto overcome some of the stigma that has impacted ondelivery and prioritisation.

And, as part of that, the Building Authority'sexpertise in infrastructure planning, design, projectdelivery, is now being leveraged for the putting forward ofbusiness cases and the management of delivery of mentalhealth projects, rather than a stand-alone mental healthbranch having those infrastructure functions themselves.

Q. So you see that as a very positive development?A. I do. I think we have seen that we've got bettercapability to build better cases and to then manageprojects. The second thing I would say is that it is alsoleading to more thought being given to new hospitaldevelopments to take account of factoring mental healthcapacity in.

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Q. Can I ask you about a different topic now, and that isto return to the subject of overall system level planning,just briefly. In the Victorian Government's submission, itsaid at 3.5.1, that:

"Responsibility and accountability forquality and safety oversight of thespecialist mental health system isdistributed across multiple bodies whichcan create a level of confusion aroundaccountability and may inhibit continuousimprovement efforts."

Can you say what that confusion is about and why it issaid that it may inhibit continuous improvement efforts?A. Certainly. So, at the moment there are many avenuesfor people to - for consumers or family members - to raisea complaint. There's lots of work that is happening tocreate protocols, information sharing, between the variousbodies but it does make for a confused space for people toknow where to go to get an issue resolved, so that's thefirst thing.

The second thing is, I think that, in terms of thepoint around quality improvement, that there has beenmultiple bodies that have had a piece of the work aroundservice model development through to practice support. Thework that we've been doing in the last 12 months, andreally aided by the Chief Psychiatrist and Safer CareVictoria, is to get more clarity around the strengths andcontributions of the different parts of the system andleverage the expertise of the Chief Psychiatrist in termsof really deep, deep, clinical knowledge of the system andSafer Care Victoria's methods of working with clinical andconsumer communities to develop service models and to buildthe kind of agreement that they should then be the basis ofwhat is more consistently delivered in the system.

So, I think we are working our way through that, but Iwould well accept that, for the service providers, thatthere still seems to be lots of bodies, how do they all fittogether.

Q. On the question of models of care, in your statementyou have said:

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"Following the identification ofpopulation-level need, as a commissionerthe Department is responsible for providingclarity as to appropriate models of care,with a focus on what funded services areexpected to deliver."

There's no ambiguity about that role?A. Yeah, so, the only thing I would say, and I think wego on to say this later in the statement, is that, indeveloping those service models it is critically importantthat there is that clinical and consumer input.

Q. Of course.A. And secondly, that it is really important that thelevel of definition leaves sufficient flexibility so that aservice model can be tailored to the needs of a localcommunity. So, for example, how a service model is appliedto an Aboriginal community, or to a refugee community, willhave different elements to it, and so I wouldn't want it tobe sort of read as an absolute that it's one size fits alland a level of prescription that is counterproductive.

Q. Certainly. Models of care are rolled out, are theynot, in other areas of health?A. Correct, that's right.

Q. It's correct, isn't it, that in mental health we'relagging behind somewhat in doing this?A. That's right. So, the mental health clinical networkreally follows the experience from acute health about theway to do this work, and again I see it as a great benefitof having integrated mental health much more deeply intothe health stewardship functions of the Department, thatwe're able to leverage that capability.

Q. Thank you. On a slightly different topic, thesubmissions have acknowledged that there's no overarchingframework for service planning to address mental healthpromotion, illness prevention and early intervention inVictoria. I just have one question: do you accept thatthere should be one?A. Yes, and again, that it needs to interface withPrimary Health Networks who will also have a critical rolein that.

Q. Finally, on strategic frameworks, the Auditor-General

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found that there was no strategic framework to guide andcoordinate the Department or health services that areresponsible for children and young persons' mental healthservices: do you accept that finding?A. Yes, and I do think it's important to distinguishbetween children and young people, and I think goingforward, and in a lot of these areas the value of the RoyalCommission in providing insights about where to go next. Ithink there are quite different views, particularly in thechildren's space, about what that framework should entail.

Q. I'm not asking you right now what it should be,because we'd probably be here more than all day, but whywas there no strategic framework? Is it the issue you'vejust alluded to or something different?A. I think it is a combination of there being deepengagement and different views around what the bestframework should be, and I think for young people there hasbeen a kind of bringing together - and I think this ishappening - of the sort of psychosocial perspectives andthe clinical perspectives. So, it's not so much - in thechildren's space I think it's a much more contest in theclinical space about what the right model is; in the youthspace I think it's more that there's been a maturationabout how the different elements could be brought togetherof a multidisciplinary response.

Q. But there's no disagreement --A. And it should be there.

Q. -- that despite clinical complexity and differences ofviews, there should always be a strategic framework?A. Absolutely. I think it's a really critical prioritygoing forward.

Q. On the question of governance and leadership, you'vementioned in your statement that two events have catalyseda significant shift in the focus and resourcing of theDepartment's system leadership responsibility since 2015:the first was the events that led to the targeting zeroreview, or the Duckett report, about hospital safety andquality in October 2016, and the second was theunprecedented surge in asthma and respiratory disease afterthe thunder storm of November 2016.

With that background, noting that neither of those isin mental health, but you raise them in your statement

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anyway because they relate to the Department's leadershipcapabilities, you've said:

"Both have led to a strengthening of theDepartment's stewardship responsibilities,with work continuing to strengthenengagement with health CEOs ...", and soon.

The Duckett review found, did it not, that the Department,at least in that context, had inadequate overarchinggovernance and oversight of safety and quality inhospitals, and that one issue giving rise to that wasinadequate data?A. I think it was more than --

Q. Perhaps one?A. One of the factors was inadequate data yes.

Q. I take it, you've raised that issue in your statementbecause you reflect on that experience as saying somethingabout the issues with leadership in the Department andyou're making the point that, since that time, steps havebeen taken to improve the Department's stewardship?A. Yeah, I wouldn't frame it so much as leadership, Iwould frame it as emphasis and resourcing.

Q. I see, can you say what you mean by that?A. Absolutely. So, I think that what came out of theDuckett review was the importance of us being more deeplyconnected with health services about strategic developmentof the sector.

That within a devolved model - and this is the secondpoint where the Auditor-General and I have a nuanceddifference of view - but in a devolved system ofgovernance, that there is a critical stewardship role forthe Department to help bring people together to look atsystem level issues that can't simply be solved by anindividual health service. That in part goes to the dataand access to information, but it also goes to model ofcare development, it goes to facilitating joint solutions,it goes to having the mechanisms for collaboration earlierin policy processes to joint problem solve.

Q. So your evidence is that, on each of those, theDepartment has come on a journey since that review --

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A. And still has a way to --

Q. -- and are still on that continuum?A. And I think we've heard evidence today about theopportunity for us to go even further in mainstreaming toembed the work on Statements of Priorities and performancediscussions in the existing stewardship mechanisms that thehealth system have and have been maturing - sorry, thehealth stewardship function has, and mental health ispartially in those, but I think has predominantly been inthe focus of Emergency Department management rather thanthose broader aspects of service model development andcollaboration.

Q. There's a number of things you mention in yourstatement that we don't have time to address in thatrespect. Can I ask you, I think you mentioned Statementsof Priorities just a moment ago. How are mentalhealth-specific KPIs included within health servicesStatement of Priorities?A. So, there are now seven KPIs that are specificallyabout mental health that are embedded in the Statement ofPriorities. In addition, there are general KPIs thatrelate in particular to Emergency Department access thatalso include mental health, and there is a specificobjective in this year's Statement of Priorities aroundworking collectively as a system to look at the very issueswe've been talking about, about meeting the needs of mentalhealth patients that is more explicit in this year'sStatement of Priorities.

Q. Leaving to one side this year, and I think thepreceding two years where there have been changes, for howlong had the mental health KPIs remained the same?A. The mental health KPIs, which is a slightly differentquestion to what's in the Statement of Priorities --

Q. Sorry, in the Statement of Priorities I mean.A. Sorry, my understanding, and this does precede me, myunderstanding is that they've been evolving since 2014/15.

Q. So, before that time they were static?A. They were managed separately and, as I understand it -and I can take this on notice and confirm for you theprecise trajectory - but my understanding is that there hasbeen an increase of KPIs sort of year-on-year from 2014/15to now.

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Q. And as of 2019, a strategic priority of supportingmental health systems will be included in all Statements ofPriority?A. Yes, and that's both for - just to make that crystalclear, I know there was evidence that was discussed in theprevious hearing - that is both relevant to health servicesthat are responsible within their catchment, as well asother health services who still need to manage referralpathways, for example.

Q. How will that be monitored? How does one, as systemleader, know whether a service who has that in theirStatement of Priorities is supporting the mental healthsystem?A. So we have performance discussions on a quarterlybasis with the health services, and that will form part ofthose discussions.

Q. If you don't know, just say, but do you know how itwill be determined whether or not the service is doingwhatever that might mean?A. Yeah, and what - I can't give you the specifics onthis one, but what generally happens with anything in aStatement of Priorities is, there is a discussion andevidence that is furnished about how Boards are meetingtheir expectations under the Statement of Priorities.

Q. Would it be fair to say that there's probably a way togo in developing an understanding of what is required inorder to meet that KPI?A. And also, I think that the link between that and theperformance management framework which is being finalisedat the moment.

Q. Thank you, I was just going to ask you about that. Myquestion is, how far away is that from being ready to beimplemented?A. Yes. So, the performance management framework wasfunded in the 2018/19 budget, it's well underway, it'sexpected to be completed by the end of this year for thenformal roll out in the 2020/21 year, and it will be moreembedded in the Statement of Priorities from next year.

Part of the reason for that timing is to line up withthe national performance framework which is expected to becompleted by early next year.

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Q. Will that include measures of the ability of servicesto meet demand?A. So, it will have access indicators within it.

Q. Different from the existing KPIs?A. We are looking at - the conversation earlier aboutsome of the feedback that's come from the Auditor-General,as well as other advice that we had commissioned, is beingbuilt into that performance management framework.

Q. Thank you, Ms Peake. Just some questions aboutEmergency Department wait times. The Royal Commission'sheard evidence that, according to the National EmergencyAccess Target, the wait time for Emergency Departmentpresentations for the general population is four hours andfor mental health population it's eight hours. Can youclarify whether that is correct?A. So, it is not quite correct. So, the four-hour targetapplies to anyone who presents at an Emergency Departmentincluding a mental health patient. Similarly, the 24-hourtarget applies to everyone in an Emergency Department.

The eight-hour target is an extra safeguard, if youlike, because we know from the data that there are anover-representation of people, with mental health patientswho are spending longer, unacceptably long periods of timein Emergency Departments, and so, rather than waiting fromfour hours to 24, there's another trigger point. It was apre-existing measure but we've kept it to provide thatextra sort of view on the system about what's happening inEmergency Departments.

Q. So, accepting that you should have as many views asyou can on what's happening in Emergency Departments, therationale for the eight-hour period is an understandingthat mental health patients will wait longer in EmergencyDepartment generally?A. No, the data is showing us that they are waitinglonger, and so, that we want to have another trigger in thesystem.

Q. The evidence is also to this effect: that mentalhealth patients are by far and away the most representedwhen wait times for movement between Emergency and aninpatient bed exceed 24-hours: do you accept that?A. That is correct.

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Q. The evidence was also that in at least some hospitals,a 24-hour breach in relation to a mental health patient,whilst it's understood is a breach and not acceptable, itwould not be subject to the same kind of examination as itwould in the case of a general health patient for thereason that there are very few, if any, options availableto Emergency Departments to deal with mental healthpatients?A. That's right. So, it's not a matter of there beingless priority or less care, it's that the examination is,sadly, often able to be completed more quickly because thereason is capacity in the system.

Q. It's really not an acceptable situation, is it?A. It's not, that's right, which comes back to theconversation we had right at the start of this hearing,about the pressures the system is under.

Q. Just to finish that off, if there is a 24-hour breachfor a mental health patient, is that required to bereported to the Department?A. It is immediately to be reported to the Department,and obviously that forms a really important part of theevidence base that flows through into budget considerationsas well.

Q. Is there a different process or policy forinvestigating 24-hour breaches for mental health andgeneral patients?A. No. The policy is the same, the practical - as we'vejust indicated, the practical way in which it plays outbecause of the shortness of the examination that's usuallyrequired, means that it looks a bit different in the levelof examination that's required, but the policy is the same.

Q. Yes, so there are really very few, if any, options toameliorate that situation in the current system?A. And I think that is exactly why - the scope of themental health Royal Commission - to be looking across thewhole stepped care model is so critical, that simplylooking at the flow of patients into inpatient is not goingto solve the problem of how many people are waiting forunacceptable periods of time in an Emergency Department.

Q. On the question of funding, in your evidence and inthe Victorian Government Solicitor's, it's accepted I think

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that current funding mechanisms specifically referring toblock funding is unresponsive to changes in population andinflexible to needs, funding's been allocated on ahistorical basis, and it's not adjusted for the wider anddisparate needs in the complexity of clients.

There have been numerous other parts of the evidencedealing with the complexities and problems with the fundingmodel. Why is it that inappropriate funding models havebeen allowed to persist for such a long period of time?A. And it is equally a very complex, expert, technicalexercise to get the alternative right. I think there wassome evidence led in Ms Williams' hearing, that the firstgo at this actually was in the 1990s, where theCommonwealth attempted to design an activity-based fundingmodel. Between 2012 and 2015 the Department did design amodel, it got to the point of being shadowed in healthservices, but the classifications within it were notsufficiently robust, and what we saw was enormousvolatility.

So, shadowing means that it's not actually used toallocate money but you measure for the year what would havehappened if it had been in place. And so, when mentalhealth was reintegrated into the broader health branch ordivision in 2016, one of the opportunities that arose wasfor the people who are actually responsible for healthfunding to take much more of a leadership role in relationto looking at activity-based funding, particularly in a waythat would enable there to be packages of care along thespectrum, and have been working really closely with theIndependent Health Pricing Authority to look at both, howdo you classify those phases of care and complexity ofpatient need within those phases of care, and then what thecosting models would be.

There is enormous work that is going on with consumerand clinical experts to look at how you do define thosephases, so that there is stability and predictability inthe model with a view to then having a shadow process, andwe've been really actively involved in that.

Again, I would reiterate, the expertise that we havein the health funding team, actually people who design casemix in the first place for the whole country, reside inthat unit, so there's deep expertise that wasn't availablebetween 2012 and 2015 when mental health was trying to do

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it on its own.

Q. Acknowledging that it is complex and acknowledgingthat mental health is not the same as general health,nevertheless in general health you've had activity-basedfunding for a very long period of time, accepting thecomplexity, are there systemic reasons why the fundingmodels have been allowed to continue for so long?A. I think it is important to say that parts of physicalhealth don't have activity-based funding that have moresimilar characteristics to mental health. So, more of theoutpatient and community-based delivery, more of the notionof what is the approach to thinking about a pathway ofcare. Similarly we are at pretty early stages in physicalhealth of designing those sort of funding models that arefit for purpose for that as well.

I think two things: I think the activity-based fundingwas originally very much designed for a model of care thatwas about infectious disease and trauma, and that was thepriority and so there was a relative priority that wasgiven. As the burden of disease has increasingly shiftedto chronic disease, that the very complex technical workhas started, including for mental health, about what avariation of an activity-based funding model might looklike.

Q. And --A. I should say, we'll be the first place anywhere in theworld, if and when - when - we get this right.

Q. That sounds good, Ms Peake. So, there's a process ofreform in which, just to summarise, a lot of work ishappening and the Department and Treasury and others andvarious experts are considering funding alternatives toblock funding, and without going to the detail, am I rightin thinking that's not just limited to activity-basedfunding, but you're considering a range of other options aswell?A. Yeah, and for different parts of the key journey,that's correct.

Q. On funding further, in 2019 to 2022, for that period,there was a very significant increase in the mental healthbudget compared to 2014/15, it was a 42 per cent increase.Without disclosing information subject to public interestimmunity claim, what were the big factors that led to that

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increase being able to be granted being successful?A. I think it really does go back to our earlierconversation about what are the factors that are important.I think there has been, you know, really strong politicalleadership, there has been a recognition within thecommunity about the pressure the mental health system isunder, and the sorts of investments that have been madehave been pretty targeted to be able to provide earlyresults in relation to alleviating some - a little bit - ofthat pressure.

It is probably worth saying that, when you look at therate of growth between 2010/2011 and 2018/19, the rate ofgrowth is pretty comparable between acute health and mentalhealth; the base that we were coming from in mental healthhas really been the problem about that funding resource.So much more work is needed to get to anywhere near a levelof capacity in the system that is needed.

Q. I just have a few more questions for you, Ms Peake.Commissioners, I won't be too much longer. On thisquestion of prioritisation, you've used the interestingexpression in your statement about "lack of parity ofesteem of mental health as compared to physical health",and you've said that lack of parity of esteem is:

"... evident in the social determinants ofmental health ... in the treatment gapsevident across our mental health system,and in the fabric of mental healthinfrastructure, which falls behind generalhealth care environments in terms ofcontemporary expectations."

Can I just explore that a little. Do you have a viewabout where the lack of parity resides, in whoseperception?A. Yeah, I think that, certainly coming back to thepoint around evidence, stigma and discrimination stillexisting particularly I think for severe mental illness andparticularly in relation to psychotic illnesses andpersonality disorder conditions - which is not to discountstigma in relation to depressive and anxiety disorderseither - I think that is absolutely at the heart of this.

I also think that, by virtue to some extent, even asmainstreaming has occurred, there's still been some

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separation, not thinking and talking about mental health asa really critical specialty like any other - like cancer,like cardiac - that we haven't helped in building thatesteem. And again, I just can't underscore enough howimportant I think this Royal Commission is to counter someof that.

Q. Can I just ask you about that stigma. Do you mean toconvey that there is a perception amongst those who makedecisions about prioritising about what the communitythinks, or something different?A. Yeah, so I think, in terms of the communityexpectation and the community acceptability, if you like,of where priority should be placed.

Q. Thank you. In relation to a question of how you makereform stick and how you implement it properly, there are anumber of things in your statement that we are interestedin. One thing you've talked about is having an adaptiveapproach, and I think you've already covered having theright tempo for reform, the right pace and staging, and theneed for careful up-front planning and so on.

Noting we don't have a lot of time, is there somethingyou want to say to the Commissioners about the question ofpace and timing?A. Yeah, look, only that there is this very fine balancebetween having early progress that maintains momentum forreform and builds that community acceptability andconfidence, with seeking to have too many different partsall being implemented at once so that theinter-dependencies can't be well managed, and that theopportunities that may arise as elements of reform unfoldthat you couldn't have even predicted when you started, theopportunities might be missed.

And so, my reflection would be, the more that we canframe a reform agenda that has practical, actionablecomponents that can be implemented and then built on, Ithink that builds the sustainability of the reform.

Q. You've mentioned strong institutional governancearrangements are necessary, including at ministerial level,Cabinet Committees and Task Forces. Is there anything morespecific you want to say about that aspect of it?A. No, I think that's - yeah.

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Q. I thought you would say that. You've also said inyour statement that robust system level governance isnecessary. I think you've probably said quite a few thingsabout that in your evidence. You mention the desirabilityof establishing an independent monitoring body to helpprovide assurance to both government and the communityabout sector capability and performance.

A. Yeah, just before I go on to that, just the bit thatyou just mentioned about the service level governance: Ithink the other point that I made in there that I wouldreinforce, is that I do think that there is value in havinga strong, stable public institution that is a fulcrum ofthat service level governance that has an enduring, bothconnection to the values of the reform ambition, but alsohas the sort of stability and endurance to be able to keepthat momentum happening at the service delivery level, aswell as the sort of things that would be put in place atthe system level. So ministerial committees andcross-government senior officials structures will get yousome way; it's the people, that strong leadership on theground that really matters.

I think where I have seen, and I've given someexamples in my statement, something new being created, it'squite difficult to form and provide that leadership forsignificant ongoing reform at the same time.

Q. So, in order to address that, what kind of structurewould you have in mind, can you say?A. And, I think that's something that we need to keepkind of talking about in the next few months.

Q. Of course.A. But in principle I think that at least the principleof having something in place, that there is an existinginstitution that has the capability to hit the groundrunning and will endure is a pretty important ingredientfor success.

Q. Finally, Ms Peake, do you have a view about thisissue, and that is, that as we saw at the outset of yourevidence by looking at the 2009 report, this is anenvironment where much is understood, although there is alot of complexity, and there's been a wealth of reports andrecommendations often saying very much the same thing, andwe at the same time see a persistence of the very same

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problems over long periods of time. If you have toidentify the key reasons why it is so hard to actually getto where we aspire to in mental health, what are they?A. So, I think absolutely part of it is having thatresourcing for change, not only for capacity but actuallyfor change. It is having the authority and accountabilityfor leading the change embedded at that service level. Itis having the mechanisms, not only for operationalgovernance, but for that collaborative governance with allparts of the system; I don't think we've had that veryeffectively in the past. There is some prospect withPrimary Health Networks for there to be a mechanism, astronger mechanism, for that work.

I think the other thing we haven't done well in thepast is, we haven't really engaged the privatepractitioners in that system level or that servicedeliverable governance. And I've included an example,which actually was referred to in the 2009 work as well,about the integrated cancer services as a bit of a model,that mightn't be quite right, but there are some learningsfrom it that I think we could take.

I think it's the resourcing, it's the political sortof authority that having a Royal Commission gives, and thenit's having those right institutional and, in particular,service level governance structures to drive it forward.

MS NICHOLS: Thank you, Ms Peake. Chair, do theCommissioners have any questions for Ms Peake?

CHAIR: Q. Thank you, Ms Peake, I have one. We've heardvery clearly throughout your evidence today and theevidence of other people who have come before thisCommission and in our community consultations and otherthings, about the daily experience of the demand pressureson the mental health system.

We've heard about so many of the strains on thecommunity-based services as well as the hospital-basedservices, and we've also heard about the disparity andavailability of services across the state, so a lot ofpilots that haven't gone to scale which means that you geta different level of service in one area compared toanother.

And so, when we think about the task ahead, I guess

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I'm interested: you mentioned lead times, the lead timesthat are involved in developing a plan, securing thefunding, establishing the infrastructure and then gettingthe workforce to actually be able to staff that, forexample.

Traditionally in mental health, or in health morebroadly, what are the lead times that you think we as aCommission need to be conscious of?A. So, and again, I think that having things happening atthe same time as the bigger change, having more of a leadtime is important to build that belief. So, I think thereprobably needs to be sort of a year for development and arealistic sort of three to five-year timeframe for phasedimplementation, but even in that first year trying to takesome of the demand pressure out is, I think, reallycritical for people feeling that they can lift themselvesout of the burden of that acute pressure that everybodyfeels at the moment to engage with what could be differentservice models and what could make a longer termdifference.

Q. A final thing was also, just to take up the point thatyou said, and it was specifically in relation to fundingmodels: you talked about the fact that now you are seekingto use the capability, not just in the mental healthbranch, but in the data analytic and other capabilityyou've got in the health part of the broader portfolio. Isthat your intention to do that more, in terms of otheraspects of the functioning and designing of mental healthand the response to mental health issues?A. It is. I think I mentioned Safer Care Victoria andthe work that they do on service model development: there'sfantastic work that they've done, for example, in strokecare which has led to clot retrieval services being morestandard for the state.

So they, with the clinical networks, now have a verystrong methodology for this work, and they are auspicing anew six-month-old mental health clinical network, so theyare a really important capability.

The other piece that I really haven't mentioned is oursystem Analytics Unit that is doing a lot of work onlinking data from health and human services to reallyunderstand what the contribution of all of our services canbe to improving wellbeing as well as health and safety

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outcomes. That unit was given status as a linkingauthority, national status, about a year ago which meansthat they are able to also link in Commonwealth data. So,we're at a point with that group where they've linked allof the DHHS data, they've now got education data andjustice data, including corrections and police data thatthey have linked in, with of course appropriate protectionsaround privacy central to that.

We've done some specific projects with theCommonwealth, particularly in cardiac care to look atvariation in care, so that authority or that capabilitywill be, I think, really critical for us in thinking about,not only what we've been focused on today about the mentalhealth system but its interface with other criticalservices.

Equally, our strategic policy area is leading the workon engagement with the Commonwealth about interface issueswith the NDIS and aged care, and that is an importantfunction and capability that we are using for the mentalhealth interfaces as well.

And finally, the research and evaluation capabilitywithin the Department, which again, I think has got areally important role if we go back to how do we avoidhaving trials that don't have a proper path to scale.

Q. Thank you. I think the other issue we just take onnotice is that issue of the Commonwealth-state relationshipin mental health that appears to be pretty fundamental tothe future design --A. Yes, absolutely.

Q. -- and better leveraging of shared interests, I think.A. If I give a one minute burst. I think the next, sothe Sixth National Mental Health Plan, is due to bestarting next year and is a significant opportunity for usto think about some of those issues around funding models,data and performance, consistent datasets. So, not onlyinitiatives, but actual fundamentals of a stepped caresystem.

There's also work that's going on in suicideprevention, both a health driven plan, but also with thenew Suicide Prevention Advisor thinking about the role thatall of the other community and service opportunities can

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bring to bear on suicide prevention, so I think there aresome real opportunities to leverage off, and obviously thefinal one is the work of the Productivity Commission.

MS NICHOLS: May Ms Peake be excused?

CHAIR: Yes. Thank you very much for your witnessstatement and your evidence today, Ms Peake.


MS NICHOLS: There are no more witnesses today, Chair.

AT 4.15PM THE COMMISSION WAS ADJOURNED TOFRIDAY, 26 JULY 2019 AT 10.00AM

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1764:15, 1767:15,

1767:22, 1770:17,

1775:30, 1775:33,

1778:32, 1778:47,

1779:44, 1780:15,

1781:36, 1784:11,

1790:33, 1791:29,

1798:44, 1801:4,

1803:33

abuses [2] - 1738:41,

1738:43

accept [23] - 1712:8,

1763:14, 1765:28,

1768:30, 1769:19,

1772:11, 1774:31,

1775:26, 1776:12,

1777:2, 1778:16,

1778:29, 1778:32,

1778:44, 1780:36,

.25/07/2019 (18)


1

1781:43, 1782:24,

1783:26, 1784:33,

1788:41, 1789:41,

1790:4, 1794:46

acceptability [4] -

1772:45, 1786:20,

1799:13, 1799:29

acceptable [2] -

1795:4, 1795:15

accepted [3] - 1772:9,

1784:35, 1795:47

accepting [2] -

1794:34, 1797:6

accepts [1] - 1761:31

access [47] - 1698:44,

1699:26, 1703:21,

1703:22, 1703:25,

1704:38, 1705:3,

1705:5, 1705:8,

1705:12, 1705:16,

1705:18, 1705:21,

1707:36, 1707:38,

1707:41, 1712:15,

1712:27, 1716:21,

1718:2, 1730:6,

1734:44, 1739:33,

1743:46, 1754:30,

1754:34, 1765:21,

1771:23, 1778:18,

1778:19, 1778:31,

1778:39, 1778:46,

1779:10, 1779:17,

1780:20, 1781:38,

1781:43, 1781:46,

1782:9, 1782:13,

1784:28, 1791:41,

1792:24, 1794:4

Access [11] - 1698:34,

1698:40, 1698:42,

1705:3, 1758:40,

1765:2, 1765:17,

1769:32, 1772:1,

1784:23, 1794:15

accessibility [1] -

1781:42

accessible [2] -

1733:18, 1768:2

accessing [4] -

1704:35, 1704:46,

1770:10, 1784:18

accommodate [2] -

1717:23, 1758:31

accommodation [1] -

1752:6

according [2] -

1746:36, 1794:14

accordingly [1] -

1746:34

account [4] - 1703:16,

1776:36, 1785:19,

1787:46

accountability [21] -

1702:46, 1703:14,

1703:26, 1703:29,

1703:34, 1703:45,

1704:11, 1706:28,

1710:26, 1710:32,

1711:17, 1735:34,

1738:27, 1743:11,

1750:6, 1750:24,

1750:45, 1788:7,

1788:12, 1801:6

accountability" [1] -

1711:9

accountable [2] -

1743:20, 1743:23

Accounts [2] - 1698:9,

1698:10

accurate [1] - 1765:28

achievable [1] -

1712:28

achieve [13] - 1706:7,

1706:10, 1708:19,

1709:2, 1720:20,

1721:21, 1721:22,

1721:23, 1729:21,

1740:28, 1751:39,

1780:5

achieved [4] -

1700:30, 1702:47,

1762:47, 1784:12

achievement [1] -

1768:45

achieving [2] -

1708:34, 1718:9

acknowledged [4] -

1764:9, 1778:9,

1785:24, 1789:38

acknowledging [8] -

1760:34, 1764:3,

1771:46, 1775:25,

1777:44, 1784:47,

1797:3

act [1] - 1716:39

Act [6] - 1698:7,

1698:17, 1698:26,

1698:33, 1758:21,

1771:10

acted [1] - 1785:3

action [9] - 1707:33,

1710:15, 1711:44,

1712:7, 1751:34,

1767:30, 1770:1,

1780:30, 1784:30

actionable [2] -

1783:4, 1799:38

actions [12] - 1699:14,

1702:5, 1705:29,

1707:21, 1707:45,

1709:25, 1709:39,

1711:13, 1717:23,

1717:32, 1778:11,

1780:32

active [1] - 1767:3

actively [4] - 1734:4,

1734:6, 1770:8,

1796:41

activities [4] - 1698:1,

1754:15, 1783:9,

1783:11

activity [14] - 1697:47,

1700:24, 1722:31,

1724:7, 1724:8,

1751:14, 1751:18,

1796:15, 1796:29,

1797:5, 1797:10,

1797:18, 1797:25,

1797:37

activity-based [9] -

1700:24, 1751:14,

1796:15, 1796:29,

1797:5, 1797:10,

1797:18, 1797:25,

1797:37

actors [2] - 1780:33,

1781:21

actual [1] - 1803:41

acute [41] - 1714:45,

1715:2, 1716:22,

1718:30, 1720:21,

1721:3, 1722:46,

1724:24, 1724:41,

1724:43, 1724:47,

1725:34, 1725:44,

1726:6, 1726:8,

1728:46, 1729:1,

1731:22, 1731:26,

1731:29, 1731:41,

1733:28, 1735:38,

1739:12, 1739:26,

1748:46, 1753:17,

1757:36, 1757:39,

1757:41, 1758:15,

1758:46, 1759:16,

1771:43, 1785:40,

1786:10, 1789:31,

1798:14, 1802:18

adamant [1] - 1740:42

adaptive [1] - 1799:19

add [3] - 1724:26,

1767:18, 1775:42

added [1] - 1742:16

adding [1] - 1776:32

addition [3] - 1741:19,

1775:42, 1792:23

additional [12] -

1726:12, 1726:34,

1731:1, 1731:47,

1742:4, 1745:1,

1745:7, 1745:10,

1745:14, 1745:26,

1745:32, 1745:45

additions [1] -

1755:14

address [23] - 1699:7,

1699:15, 1701:9,

1701:37, 1712:33,

1712:35, 1712:39,

1714:37, 1729:7,

1732:13, 1738:35,

1739:25, 1741:20,

1743:32, 1745:29,

1745:39, 1751:14,

1770:1, 1772:5,

1784:30, 1789:39,

1792:16, 1800:29

addressed [4] -

1701:25, 1718:31,

1734:9, 1747:10

addresses [1] -

1778:19

addressing [4] -

1699:21, 1699:46,

1712:18, 1772:18

adequate [3] -

1700:27, 1719:44,

1726:46

adequately [6] -

1699:19, 1700:14,

1701:21, 1718:31,

1729:41, 1729:45

adjourn [1] - 1736:33

ADJOURNED [1] -

1804:14

ADJOURNMENT [2] -

1736:35, 1755:33

adjusted [2] -

1746:36, 1796:4

adjustment [1] -

1746:34

adjustments [1] -

1771:32

Administration [1] -

1756:21

administrative [1] -

1711:31

admission [4] -

1744:6, 1744:36,

1752:44, 1758:44

admissions [1] -

1771:34

admit [4] - 1731:32,

1753:14, 1753:19,

1753:27

admitted [1] - 1782:17

adolescent [6] -

1700:36, 1701:3,

1712:16, 1742:21,

1749:37, 1750:31

adopt [1] - 1738:47

adult [1] - 1742:21

advanced [1] -

1723:31

advancing [1] -

1780:17

advent [1] - 1779:4

adverse [3] - 1748:11,

1753:33, 1780:25

advice [7] - 1699:32,

1702:29, 1768:2,

1772:31, 1785:20,

1786:45, 1794:9

advise [4] - 1709:21,

1709:28, 1719:45,

1722:17

advised [1] - 1704:3

Advisor [1] - 1803:46

Advisory [1] - 1737:19

advocacy [2] -

1745:33, 1746:10

advocate [2] -

1727:11, 1741:40

advocating [2] -

1727:13, 1745:31

affected [2] - 1764:39,

1769:36

affirmed [3] - 1713:13,

1736:42, 1755:38

AFTER [1] - 1736:37

Aged [1] - 1737:43

aged [8] - 1714:44,

1715:3, 1720:22,

1725:45, 1731:26,

1742:21, 1749:37,

1803:20

ageing [1] - 1769:43

agencies [4] -

1702:21, 1712:5,

1763:8, 1763:37

agency [4] - 1709:12,

1710:2, 1711:47,

1763:9

Agency [1] - 1775:19

agenda [3] - 1700:25,

1741:46, 1799:38

aggregate [2] -

1703:47, 1711:31

aggregated [1] -

1773:39

agitated [1] - 1740:1

ago [10] - 1737:29,

1742:42, 1744:13,

1754:43, 1762:31,

1764:27, 1769:24,

1780:44, 1792:18,

1803:2

agree [7] - 1759:2,

1759:40, 1759:43,

1764:11, 1764:29,

1779:45, 1782:11

.25/07/2019 (18)


2

agreed [2] - 1768:41,

1768:46

agreement [2] -

1746:33, 1788:37

ahead [4] - 1727:32,

1756:47, 1766:43,

1801:47

aided [1] - 1788:30

aim [1] - 1784:12

aimed [1] - 1751:39

air [1] - 1739:27

alert [1] - 1710:31

Alex [2] - 1696:28,

1734:22

Alfred [4] - 1732:39,

1737:20, 1737:32,

1745:4

align [3] - 1699:47,

1715:28, 1717:22

aligned [3] - 1717:16,

1719:11, 1731:20

aligning [1] - 1719:11

Allan [1] - 1696:27

alleviating [1] -

1798:9

Allied [1] - 1715:29

allocate [3] - 1776:36,

1785:35, 1796:23

allocated [2] -

1743:35, 1796:3

allocation [2] -

1741:44, 1742:3

allocations [1] -

1699:47

allow [2] - 1731:37,

1759:11

allowance [1] -

1726:14

allowed [3] - 1715:37,

1796:10, 1797:8

allows [1] - 1706:21

alluded [2] - 1771:15,

1790:15

almost [4] - 1699:21,

1723:37, 1725:13,

1743:34

alone [2] - 1741:10,

1787:38

alongside [2] -

1745:21, 1765:33

alright [7] - 1716:47,

1775:25, 1775:47,

1776:22, 1781:24,

1785:39, 1787:9

alternative [1] -

1796:12

alternatives [2] -

1757:42, 1797:35

altogether [2] -

1784:44, 1785:47

AM [1] - 1724:25

ambiguity [1] - 1789:8

ambition [1] - 1800:15

ambulance [2] -

1752:34, 1755:6

ameliorate [2] -

1770:27, 1795:38

amenable [1] - 1786:8

AMHSs [1] - 1700:3

amount [8] - 1703:5,

1721:47, 1722:10,

1725:31, 1734:23,

1781:8, 1781:9,

1783:18

analogy [1] - 1743:14

analyse [4] - 1704:9,

1711:32, 1774:29,

1775:30

analysed [2] - 1704:4,

1722:12

analysing [1] -

1774:18

analysis [9] - 1701:28,

1704:2, 1734:41,

1749:2, 1773:43,

1774:46, 1775:22,

1779:35, 1781:30

analytic [2] - 1772:30,

1802:27

analytical [2] - 1775:4,

1786:44

analytics [1] - 1783:37

Analytics [1] -

1802:44

Andrew [1] - 1697:2

ANDREW [1] - 1697:5

ANNE [2] - 1713:13,

1755:38

annexed [1] - 1698:37

announcing [1] -

1757:2

annual [13] - 1698:11,

1717:3, 1717:16,

1718:36, 1718:43,

1718:46, 1719:5,

1719:11, 1729:35,

1745:8, 1745:20,

1769:27, 1786:45

Annual [2] - 1781:2,

1781:25

annually [1] - 1711:47

annum [2] - 1752:37,

1752:38

answer [8] - 1712:20,

1727:11, 1732:3,

1764:20, 1774:13,

1786:27, 1786:39,

1787:4

answered [1] -

1787:11

answers [1] - 1764:13

anxiety [1] - 1798:43

anyway [3] - 1702:42,

1729:34, 1791:1

AO [1] - 1696:27

appear [1] - 1765:13

appeared [1] -

1765:46

appendix [1] -

1781:25

applied [3] - 1702:42,

1760:14, 1789:18

Applied [1] - 1713:24

applies [3] - 1748:4,

1794:20, 1794:22

apply [1] - 1748:3

appointed [2] -

1738:9, 1738:14

appointment [1] -

1697:11

appointments [3] -

1737:15, 1737:25,

1737:29

approach [10] -

1700:11, 1701:20,

1768:24, 1773:32,

1773:43, 1783:41,

1783:43, 1783:45,

1797:13, 1799:20

approaches [1] -

1763:5

appropriate [24] -

1699:12, 1702:22,

1702:40, 1702:45,

1703:20, 1703:46,

1704:36, 1704:47,

1708:44, 1709:22,

1709:28, 1712:25,

1712:26, 1727:7,

1731:37, 1742:12,

1744:32, 1763:34,

1774:18, 1780:28,

1780:29, 1785:43,

1789:4, 1803:7

appropriately [3] -

1718:37, 1730:26,

1761:23

appropriation [1] -

1762:13

approximating [1] -

1700:11

Ardern [1] - 1708:35

area [20] - 1699:37,

1716:26, 1720:39,

1721:7, 1732:10,

1734:25, 1737:46,

1737:47, 1738:2,

1739:45, 1740:24,

1741:41, 1742:20,

1749:21, 1749:24,

1754:2, 1754:19,

1767:46, 1801:44,

1803:18

Area [1] - 1699:42

areas [35] - 1699:18,

1708:32, 1711:2,

1711:25, 1711:26,

1724:2, 1725:46,

1729:8, 1735:6,

1735:7, 1735:10,

1735:11, 1739:25,

1741:43, 1746:31,

1746:41, 1747:9,

1747:10, 1747:25,

1747:47, 1748:1,

1748:14, 1749:35,

1749:37, 1749:39,

1749:40, 1750:17,

1762:36, 1764:43,

1772:37, 1772:44,

1772:46, 1789:25,

1790:7

argue [1] - 1710:13

argues [1] - 1766:14

argument [1] - 1708:4

arise [2] - 1764:7,

1799:33

arisen [1] - 1764:6

arm [1] - 1698:15

arms [1] - 1701:47

Armytage [1] -

1696:26

arose [1] - 1796:26

arrangement [2] -

1743:18, 1743:33

arrangements [6] -

1702:11, 1742:37,

1743:15, 1754:14,

1782:37, 1799:43

array [1] - 1781:21

arrival [1] - 1738:40

arrivals [1] - 1752:34

arrived [2] - 1716:8,

1716:19

arrives [1] - 1753:6

articulate [3] -

1709:11, 1709:17,

1720:29

articulated [2] -

1706:14, 1710:2

articulates [2] -

1699:16, 1699:34

articulating [2] -

1709:8, 1709:9

ascertain [1] - 1731:9

aspect [2] - 1715:8,

1799:45

aspects [6] - 1740:3,

1742:22, 1751:4,

1770:31, 1792:12,

1802:30

aspirational [5] -

1769:11, 1769:12,

1779:30, 1780:46,

1781:6

aspirations [1] -

1757:5

aspire [1] - 1801:3

assaulted [1] -

1753:34

assaults [1] - 1753:39

assess [6] - 1704:35,

1704:46, 1744:5,

1753:1, 1753:4,

1768:45

assessing [2] -

1705:16, 1761:37

assessment [8] -

1703:36, 1705:15,

1731:20, 1753:10,

1753:13, 1754:1,

1754:9, 1754:41

assist [7] - 1710:30,

1714:19, 1738:12,

1745:44, 1749:19,

1759:13, 1768:3

assistance [2] -

1737:21, 1750:12

Assistant [3] -

1697:20, 1697:22,

1762:32

Assisting [1] -

1696:33

assists [1] - 1699:4

associated [6] -

1710:16, 1739:14,

1769:1, 1769:2,

1773:5, 1782:2

assume [1] - 1760:44

assuming [1] - 1768:8

assurance [2] -

1697:39, 1800:6

asthma [1] - 1790:43

AT [2] - 1804:14,

1804:15

attached [1] - 1710:24

attachment [1] -

1752:29

attachments [1] -

1697:34

attain [1] - 1731:15

attempt [2] - 1745:14,

1746:9

attempted [1] -

1796:15

attempting [1] -

1754:8

attempts [1] - 1751:17

attend [1] - 1753:12

attendant [1] - 1710:5

.25/07/2019 (18)


3

attending [1] -

1736:30

attention [15] -

1714:47, 1716:4,

1716:6, 1716:9,

1721:32, 1734:42,

1735:1, 1739:30,

1739:44, 1741:47,

1744:24, 1747:47,

1750:34, 1750:47,

1751:41

attract [1] - 1746:10

attracted [1] - 1711:7

attractive [1] -

1726:42

attribute [1] - 1711:12

attribution [2] -

1711:14, 1780:30

Audit [6] - 1697:21,

1697:22, 1698:17,

1698:26, 1704:1,

1705:3

audit [6] - 1697:45,

1698:33, 1698:41,

1700:34, 1700:35,

1751:3

audited [1] - 1708:26

auditing [1] - 1697:26

Auditor [36] - 1697:2,

1697:7, 1697:12,

1697:16, 1697:20,

1697:22, 1697:36,

1697:38, 1698:4,

1698:14, 1698:23,

1728:44, 1765:2,

1765:17, 1769:31,

1771:46, 1772:1,

1772:29, 1773:30,

1774:22, 1775:27,

1778:8, 1778:16,

1778:29, 1779:34,

1779:45, 1780:36,

1781:39, 1782:14,

1782:22, 1782:34,

1784:23, 1785:2,

1789:47, 1791:35,

1794:8

Auditor-General [29] -

1697:2, 1697:7,

1697:12, 1697:20,

1697:22, 1697:36,

1697:38, 1698:4,

1698:14, 1698:23,

1728:44, 1765:2,

1765:17, 1769:31,

1771:46, 1772:1,

1772:29, 1773:30,

1774:22, 1775:27,

1778:8, 1779:34,

1781:39, 1782:22,

1782:34, 1784:23,

1789:47, 1791:35,

1794:8

Auditor-General's [7]

- 1697:16, 1778:16,

1778:29, 1779:45,

1780:36, 1782:14,

1785:2

Auditors [5] -

1702:18, 1702:20,

1704:16, 1704:17,

1704:21

Auditors-General [5] -

1702:18, 1702:20,

1704:16, 1704:17,

1704:21

audits [3] - 1697:42,

1697:45, 1712:6

augment [3] - 1752:3,

1754:38, 1755:13

August [1] - 1719:15

aureus [1] - 1735:5

auspicing [1] -

1802:39

Austin [2] - 1737:33,

1745:4

Australia [4] -

1710:44, 1755:1,

1756:21, 1774:10

Australian [1] -

1737:22

authority [4] - 1801:6,

1801:25, 1803:2,

1803:12

Authority [6] -

1737:19, 1751:24,

1780:45, 1786:44,

1787:14, 1796:32

Authority's [1] -

1787:34

availability [2] -

1757:46, 1801:42

available [12] -

1704:6, 1712:21,

1725:29, 1726:27,

1729:15, 1747:20,

1758:41, 1762:13,

1772:22, 1774:16,

1795:7, 1796:46

avenues [1] - 1788:17

average [1] - 1757:36

avoid [2] - 1706:19,

1803:26

aware [6] - 1705:39,

1718:44, 1722:10,

1730:22, 1767:42,

1771:14

B

Bachelor [2] -

1713:30, 1737:7

background [3] -

1754:23, 1776:23,

1790:46

balance [4] - 1725:8,

1725:23, 1748:41,

1799:27

balanced [1] - 1747:2

barracking [1] -

1708:43

barrier [1] - 1750:1

barriers [1] - 1763:7

Barwon [14] -

1714:19, 1717:11,

1719:25, 1720:26,

1720:36, 1731:33,

1731:41, 1733:27,

1737:17, 1738:7,

1738:10, 1738:15,

1738:16, 1745:4

base [3] - 1786:44,

1795:25, 1798:15

based [39] - 1700:19,

1700:24, 1703:36,

1706:35, 1708:27,

1724:15, 1725:45,

1726:17, 1727:4,

1738:32, 1739:4,

1742:20, 1749:21,

1750:30, 1751:14,

1751:18, 1752:4,

1754:18, 1756:40,

1757:23, 1757:42,

1758:45, 1759:7,

1759:12, 1761:1,

1768:17, 1781:29,

1784:1, 1796:15,

1796:29, 1797:5,

1797:10, 1797:12,

1797:18, 1797:25,

1797:37, 1801:40

bases [1] - 1785:41

basis [10] - 1735:20,

1735:24, 1735:25,

1768:20, 1768:40,

1769:28, 1783:17,

1788:37, 1793:17,

1796:4

Batten [1] - 1696:36

bays [2] - 1754:5,

1754:8

bear [2] - 1767:4,

1804:1

becomes [3] -

1783:20, 1783:21,

1785:35

becoming [2] -

1718:45, 1757:47

bed [15] - 1700:3,

1725:45, 1726:17,

1728:47, 1729:1,

1735:12, 1744:6,

1752:4, 1753:2,

1753:4, 1757:42,

1771:34, 1776:32,

1785:41, 1794:46

bed-based [4] -

1725:45, 1726:17,

1752:4, 1757:42

bedevils [1] - 1785:16

beds [8] - 1699:29,

1731:22, 1739:3,

1753:17, 1753:18,

1754:40, 1785:41,

1786:24

began [1] - 1716:3

behalf [1] - 1776:12

behaviour [3] -

1709:40, 1767:34,

1780:24

behavioural [4] -

1734:3, 1753:47,

1754:9, 1754:41

behaviours [1] -

1710:9

behind [4] - 1741:14,

1766:26, 1789:29,

1798:31

belief [1] - 1802:12

benchmark [1] -

1723:35

benchmarking [2] -

1723:44, 1733:19

benefit [3] - 1715:34,

1758:43, 1789:32

benefits [6] - 1710:14,

1745:18, 1768:25,

1770:45, 1774:25,

1780:45

Bernadette [1] -

1696:29

best [13] - 1703:21,

1703:22, 1703:25,

1707:47, 1710:41,

1730:29, 1732:31,

1743:43, 1761:17,

1762:37, 1763:39,

1776:45, 1790:17

better [23] - 1705:16,

1710:47, 1711:28,

1716:45, 1730:4,

1733:42, 1742:17,

1749:40, 1754:9,

1757:9, 1762:25,

1763:32, 1774:8,

1774:37, 1777:4,

1777:5, 1781:22,

1782:18, 1785:11,

1787:42, 1787:43,

1803:35

between [43] -

1697:12, 1698:4,

1698:14, 1699:7,

1699:42, 1702:20,

1704:16, 1704:21,

1707:8, 1707:33,

1709:18, 1720:26,

1725:42, 1729:4,

1733:15, 1763:8,

1764:10, 1764:28,

1765:36, 1770:25,

1772:5, 1772:18,

1772:43, 1773:23,

1774:23, 1775:43,

1776:47, 1779:29,

1780:30, 1780:38,

1781:46, 1785:32,

1787:30, 1788:20,

1790:6, 1793:32,

1794:45, 1796:16,

1796:47, 1798:13,

1798:14, 1799:28

beyond [1] - 1731:29

bid [1] - 1746:18

bids [4] - 1745:21,

1745:22, 1746:2,

1746:4

big [5] - 1716:14,

1718:14, 1731:18,

1755:4, 1797:47

bigger [2] - 1775:2,

1802:11

birth [1] - 1714:39

bit [36] - 1706:38,

1716:11, 1716:47,

1717:4, 1719:7,

1719:29, 1720:11,

1720:17, 1722:30,

1722:35, 1723:42,

1724:45, 1725:7,

1727:43, 1729:32,

1738:21, 1745:24,

1745:29, 1750:44,

1754:22, 1759:37,

1765:42, 1765:43,

1766:23, 1769:17,

1770:29, 1774:13,

1776:40, 1782:26,

1783:43, 1785:23,

1786:16, 1795:34,

1798:9, 1800:9,

1801:20

bits [1] - 1724:26

blind [2] - 1711:8,

1743:38

block [7] - 1734:20,

.25/07/2019 (18)


4

1734:22, 1734:23,

1751:17, 1773:17,

1796:2, 1797:36

Blood [1] - 1737:31

blood [1] - 1735:5

blown [1] - 1745:17

blueprint [2] -

1740:23, 1741:5

blunt [1] - 1781:16

board [10] - 1720:4,

1726:20, 1737:15,

1737:18, 1737:25,

1737:28, 1738:7,

1738:15, 1738:16,

1774:28

Board [50] - 1711:29,

1717:15, 1718:21,

1718:22, 1719:1,

1719:15, 1719:32,

1719:35, 1720:7,

1720:31, 1721:30,

1721:32, 1721:38,

1722:1, 1722:4,

1722:6, 1722:7,

1722:13, 1722:18,

1722:34, 1733:7,

1734:43, 1735:1,

1735:19, 1735:23,

1735:28, 1735:43,

1737:17, 1737:19,

1738:10, 1743:10,

1743:20, 1743:23,

1743:25, 1743:37,

1744:19, 1745:13,

1747:20, 1748:17,

1748:22, 1748:33,

1748:36, 1748:37,

1748:42, 1748:45,

1750:34, 1750:38,

1751:25, 1753:35,

1782:33

Board's [1] - 1744:24

boards [12] - 1719:42,

1720:11, 1720:14,

1737:17, 1737:30,

1744:37, 1748:11,

1748:12, 1748:13,

1748:15, 1748:29,

1748:39

Boards [2] - 1719:43,

1793:26

bodies [4] - 1788:10,

1788:21, 1788:27,

1788:42

body [1] - 1800:5

bottom [6] - 1724:22,

1725:16, 1759:35,

1760:2, 1767:27

bottom-up [2] -

1724:22

boundaries [3] -

1749:34, 1749:38,

1784:17

boundary [1] -

1784:36

box [2] - 1760:2,

1769:39

BP [1] - 1706:46

branch [13] - 1727:16,

1727:24, 1727:25,

1727:32, 1727:37,

1727:46, 1727:47,

1728:19, 1746:1,

1756:21, 1787:39,

1796:25, 1802:27

brave [1] - 1757:7

breach [3] - 1795:3,

1795:4, 1795:20

breaches [1] -

1795:29

break [4] - 1736:29,

1755:29, 1755:31,

1783:4

Brian [1] - 1739:27

brief [1] - 1699:10

briefly [7] - 1697:35,

1729:33, 1737:40,

1759:23, 1771:15,

1784:22, 1788:4

bring [9] - 1711:31,

1738:30, 1739:9,

1741:18, 1750:23,

1779:44, 1785:8,

1791:38, 1804:1

bringing [3] - 1715:46,

1719:10, 1790:19

brings [1] - 1767:20

broad [5] - 1717:35,

1742:41, 1768:4,

1781:21, 1785:44

broader [9] - 1732:21,

1739:22, 1748:6,

1748:7, 1758:5,

1787:24, 1792:12,

1796:25, 1802:28

broadly [5] - 1704:27,

1706:1, 1715:1,

1777:42, 1802:8

brought [3] - 1719:9,

1767:4, 1790:25

Budget [2] - 1706:42,

1708:24

budget [52] - 1698:11,

1707:29, 1708:36,

1708:42, 1721:19,

1724:12, 1724:14,

1724:21, 1724:27,

1724:29, 1724:32,

1725:17, 1725:23,

1725:41, 1726:14,

1726:20, 1726:28,

1727:21, 1727:23,

1727:26, 1727:30,

1727:33, 1727:41,

1729:16, 1729:18,

1729:29, 1731:7,

1741:44, 1742:3,

1742:5, 1745:8,

1745:20, 1745:21,

1745:22, 1745:38,

1745:46, 1746:2,

1746:4, 1746:6,

1746:18, 1746:31,

1746:36, 1746:45,

1747:2, 1751:40,

1783:31, 1786:45,

1793:40, 1795:25,

1797:45

budgetary [5] -

1706:35, 1707:12,

1708:29, 1708:37,

1709:26

budgeted [1] -

1746:22

budgets [6] - 1721:18,

1727:15, 1727:17,

1727:20, 1729:27,

1786:23

build [10] - 1731:25,

1761:25, 1765:29,

1773:1, 1783:3,

1786:20, 1786:44,

1787:43, 1788:36,

1802:12

Building [3] - 1786:44,

1787:14, 1787:34

building [7] - 1726:46,

1728:23, 1731:18,

1734:28, 1774:11,

1777:16, 1799:3

builds [3] - 1724:21,

1799:29, 1799:40

built [6] - 1734:26,

1734:29, 1739:12,

1742:30, 1794:10,

1799:39

Burdekin [3] -

1739:27, 1739:37,

1740:36

burden [2] - 1797:22,

1802:18

bureaucracy [1] -

1747:14

burst [1] - 1803:36

busiest [3] - 1752:31,

1752:35

business [17] -

1717:3, 1717:16,

1717:24, 1717:31,

1717:33, 1718:13,

1718:36, 1718:44,

1719:5, 1719:11,

1719:14, 1719:21,

1733:37, 1745:17,

1766:21, 1787:37

busy [1] - 1749:16

C

Cabinet [6] - 1705:40,

1741:24, 1741:36,

1756:3, 1756:17,

1799:44

cancer [2] - 1799:2,

1801:20

cannot [4] - 1698:17,

1733:7, 1742:4,

1749:32

capabilities [5] -

1764:46, 1774:40,

1775:23, 1782:26,

1791:2

capability [28] -

1702:30, 1729:11,

1774:6, 1774:7,

1774:10, 1774:11,

1774:16, 1774:29,

1774:32, 1775:4,

1775:11, 1775:20,

1775:44, 1776:14,

1782:27, 1782:29,

1782:43, 1782:47,

1787:43, 1789:35,

1800:7, 1800:37,

1802:26, 1802:27,

1802:41, 1803:12,

1803:21, 1803:24

capable [1] - 1705:16

capacity [21] -

1699:20, 1719:40,

1749:17, 1758:30,

1760:15, 1771:23,

1772:12, 1775:30,

1775:36, 1776:32,

1776:37, 1777:20,

1779:38, 1781:41,

1783:31, 1785:34,

1786:10, 1787:47,

1795:13, 1798:18,

1801:5

capita [1] - 1776:28

capital [16] - 1703:10,

1703:12, 1728:8,

1729:28, 1729:29,

1729:31, 1731:12,

1731:18, 1731:19,

1734:17, 1739:11,

1741:20, 1745:16,

1765:23, 1785:24

capture [4] - 1699:25,

1700:14, 1703:46,

1761:10

captured [2] -

1705:20, 1773:38

cardiac [2] - 1799:3,

1803:11

Care [4] - 1713:27,

1788:30, 1788:35,

1802:32

care [82] - 1701:16,

1713:43, 1714:36,

1714:38, 1714:39,

1714:44, 1715:3,

1715:41, 1718:30,

1718:31, 1720:23,

1720:30, 1720:32,

1720:38, 1721:2,

1721:10, 1721:12,

1721:15, 1722:20,

1723:46, 1724:24,

1726:22, 1731:7,

1731:38, 1731:39,

1732:17, 1732:19,

1732:20, 1732:31,

1733:1, 1733:15,

1735:16, 1735:17,

1738:46, 1739:13,

1742:22, 1747:47,

1749:31, 1749:32,

1754:4, 1754:44,

1754:47, 1757:23,

1757:26, 1760:15,

1760:45, 1761:11,

1761:18, 1761:19,

1761:20, 1766:26,

1771:23, 1771:32,

1771:42, 1773:19,

1777:7, 1778:11,

1780:4, 1780:34,

1781:19, 1785:7,

1786:14, 1788:45,

1789:4, 1789:24,

1791:42, 1795:11,

1795:41, 1796:30,

1796:33, 1796:34,

1797:14, 1797:19,

1798:32, 1802:35,

1803:11, 1803:12,

1803:20, 1803:41

career [1] - 1713:43

careful [2] - 1762:3,

1799:22

carers [1] - 1761:14

carers' [1] - 1771:5

Carrum [1] - 1714:41

carry [1] - 1725:30

cascade [1] - 1765:38

cascades [1] -

1763:37

cascading [1] -

.25/07/2019 (18)


5

1763:44

case [8] - 1704:5,

1735:31, 1750:5,

1760:25, 1762:11,

1771:38, 1795:6,

1796:44

cases [3] - 1745:17,

1787:37, 1787:43

cast [1] - 1785:17

catalysed [1] -

1790:37

catch [2] - 1776:42,

1776:43

catchment [19] -

1699:37, 1714:37,

1742:41, 1742:42,

1742:44, 1742:45,

1742:46, 1743:7,

1749:10, 1749:24,

1749:35, 1749:39,

1750:30, 1754:19,

1784:17, 1784:37,

1784:47, 1793:8

catchments [10] -

1749:6, 1749:41,

1776:47, 1784:14,

1784:22, 1784:27,

1784:35, 1784:39,

1784:43, 1785:8

CATT [1] - 1754:15

caught [1] - 1711:14

causal [1] - 1701:27

caused [2] - 1738:38,

1770:15

caveat [2] - 1769:22,

1786:16

cent [12] - 1707:39,

1707:46, 1711:20,

1714:4, 1728:38,

1728:45, 1728:47,

1752:37, 1769:35,

1797:45

central [1] - 1803:8

centre [2] - 1702:22,

1704:28

centred [1] - 1756:39

centres [5] - 1754:47,

1755:5, 1755:6,

1755:10

CEO [6] - 1714:26,

1717:6, 1718:45,

1722:30, 1727:10,

1727:35

CEOs [1] - 1791:7

certain [2] - 1702:5,

1745:10

certainly [24] -

1723:34, 1731:36,

1734:28, 1736:1,

1736:16, 1739:34,

1740:36, 1741:11,

1745:12, 1748:30,

1748:35, 1749:34,

1749:36, 1750:47,

1755:1, 1765:41,

1777:47, 1780:43,

1782:34, 1784:20,

1787:2, 1788:17,

1789:24, 1798:38

Certificate [1] -

1713:27

cetera [3] - 1716:29,

1734:3, 1752:6

Chair [11] - 1696:26,

1710:34, 1710:39,

1718:21, 1736:28,

1742:36, 1750:38,

1755:20, 1767:19,

1782:33, 1804:12

chair [8] - 1710:19,

1734:13, 1737:2,

1737:11, 1737:16,

1737:19, 1752:18,

1801:29

CHAIR [14] - 1710:22,

1710:37, 1710:41,

1713:1, 1713:5,

1734:39, 1736:24,

1736:33, 1752:21,

1755:16, 1755:23,

1755:31, 1801:32,

1804:7

challenge [5] -

1699:15, 1763:14,

1770:32, 1772:23,

1785:35

challenges [5] -

1701:13, 1705:11,

1768:14, 1772:25,

1784:43

champion [2] -

1721:33, 1721:34

chance [1] - 1746:5

change [20] - 1699:36,

1709:40, 1711:40,

1714:20, 1715:18,

1715:31, 1716:14,

1719:4, 1719:17,

1738:46, 1742:35,

1750:13, 1768:11,

1769:33, 1771:6,

1801:5, 1801:6,

1801:7, 1802:11

changed [4] -

1715:15, 1719:7,

1740:42, 1743:5

changes [11] -

1700:22, 1715:40,

1739:9, 1749:40,

1751:40, 1751:47,

1757:17, 1760:19,

1779:8, 1792:33,

1796:2

changing [2] -

1709:45, 1764:43

characterised [1] -

1702:18

characteristic [1] -

1772:43

characteristics [5] -

1703:36, 1706:30,

1706:32, 1706:33,

1797:11

charge [2] - 1697:20,

1697:22

Chief [20] - 1713:20,

1714:9, 1714:23,

1715:12, 1715:19,

1728:27, 1737:30,

1737:31, 1737:32,

1745:5, 1748:25,

1750:20, 1750:21,

1750:39, 1750:40,

1758:11, 1758:37,

1771:14, 1788:30,

1788:33

Child [3] - 1698:36,

1700:33, 1704:1

child [10] - 1700:36,

1700:37, 1701:3,

1701:7, 1712:15,

1742:21, 1749:36,

1750:31, 1759:36,

1772:40

children [6] - 1700:43,

1701:17, 1701:22,

1758:3, 1790:3,

1790:6

children's [2] -

1790:10, 1790:22

choice [1] - 1749:27

chronic [1] - 1797:23

circumstances [2] -

1740:34, 1767:7

claim [2] - 1764:21,

1797:47

clarify [3] - 1727:19,

1766:1, 1794:18

clarity [3] - 1763:26,

1788:31, 1789:4

classifications [1] -

1796:18

classify [1] - 1796:33

cleaning [2] -

1743:19, 1743:21

clear [23] - 1705:7,

1707:43, 1707:47,

1708:20, 1719:1,

1720:37, 1728:5,

1732:23, 1732:29,

1732:45, 1762:45,

1763:4, 1768:26,

1772:21, 1775:22,

1777:26, 1779:1,

1780:30, 1781:27,

1783:36, 1787:4,

1793:6

clearly [4] - 1699:34,

1712:26, 1778:17,

1801:33

client [7] - 1700:21,

1707:1, 1726:9,

1726:22, 1732:26,

1754:26

clients [12] - 1700:14,

1721:13, 1722:20,

1724:1, 1726:11,

1726:13, 1726:23,

1726:47, 1734:2,

1780:13, 1796:5

climate [1] - 1701:14

clinical [26] - 1700:38,

1715:45, 1720:11,

1722:16, 1722:36,

1742:38, 1746:24,

1747:21, 1747:24,

1748:14, 1750:20,

1751:2, 1753:7,

1755:4, 1755:8,

1788:34, 1788:35,

1789:12, 1789:30,

1790:21, 1790:23,

1790:31, 1796:38,

1802:38, 1802:40

clinicians [7] - 1721:1,

1721:6, 1726:45,

1730:8, 1733:46,

1753:1, 1753:3

clinics [1] - 1739:14

closely [1] - 1796:31

closer [3] - 1710:34,

1710:42, 1716:17

closing [1] - 1699:41

clot [1] - 1802:35

cloud [1] - 1774:43

co [1] - 1761:12

co-producing [1] -

1761:12

Cockram [1] - 1696:28

COCKRAM [2] -

1734:16, 1734:37

COGHLAN [9] -

1713:10, 1713:15,

1734:13, 1736:28,

1736:39, 1736:44,

1752:18, 1755:20,

1755:28

Coghlan [1] - 1696:35

coherent [3] -

1719:45, 1732:16,

1732:19

cohort [1] - 1700:21

coinciding [1] -

1785:14

collaboration [4] -

1763:35, 1765:36,

1791:43, 1792:13

collaborative [1] -

1801:9

collect [1] - 1722:11

collected [2] -

1721:47, 1722:45

collection [4] -

1699:38, 1700:7,

1700:9, 1751:23

collections [1] -

1781:47

collective [1] -

1711:17

collectively [1] -

1792:27

combination [1] -

1790:16

comfortable [2] -

1733:44, 1781:7

comfortably [1] -

1731:37

coming [13] - 1722:20,

1724:2, 1724:35,

1724:39, 1725:27,

1726:17, 1729:10,

1732:27, 1732:30,

1744:4, 1778:34,

1798:15, 1798:38

commenced [1] -

1699:39

comment [5] -

1698:23, 1741:30,

1747:22, 1785:33,

1786:17

commenting [1] -

1698:27

commission [1] -

1727:47

COMMISSION [2] -

1696:5, 1804:14

Commission [29] -

1699:33, 1701:26,

1710:30, 1712:10,

1713:16, 1728:36,

1734:18, 1736:45,

1741:45, 1757:2,

1757:7, 1757:9,

1759:40, 1776:24,

1779:4, 1779:6,

1781:30, 1783:18,

1784:21, 1784:41,

1784:42, 1785:39,

1790:8, 1795:40,

1799:5, 1801:25,

.25/07/2019 (18)


6

1801:35, 1802:9,

1804:3

Commission's [3] -

1697:31, 1711:37,

1794:13

commissioned [3] -

1748:27, 1778:23,

1794:9

COMMISSIONER [2] -

1734:16, 1734:37

commissioner [3] -

1762:18, 1762:19,

1789:2

Commissioner [2] -

1762:32, 1771:22

Commissioners [12] -

1697:1, 1704:42,

1710:20, 1734:13,

1737:5, 1752:19,

1752:27, 1755:35,

1765:46, 1798:21,

1799:25, 1801:30

commissioning [4] -

1762:23, 1784:28,

1785:25, 1785:31

commitment [6] -

1741:10, 1741:26,

1741:33, 1752:11,

1765:35, 1777:36

committed [1] -

1741:13

committee [5] -

1698:8, 1698:12,

1748:22, 1767:20,

1782:33

Committee [3] -

1698:9, 1698:10,

1741:37

committees [2] -

1748:45, 1800:19

Committees [1] -

1799:44

common [3] - 1763:6,

1772:25, 1772:43

commonly [1] -

1747:8

Commonwealth [7] -

1767:2, 1767:20,

1796:15, 1803:3,

1803:11, 1803:19,

1803:30

Commonwealth-

state [1] - 1803:30

communities [2] -

1763:40, 1788:36

Community [5] -

1726:43, 1737:43,

1738:20, 1758:45,

1759:7

community [62] -

1702:2, 1714:45,

1715:4, 1721:3,

1723:46, 1726:2,

1726:36, 1729:12,

1729:14, 1729:47,

1730:6, 1731:31,

1731:32, 1731:34,

1732:4, 1732:47,

1733:2, 1733:8,

1734:17, 1734:19,

1734:21, 1734:27,

1734:29, 1735:39,

1735:43, 1738:32,

1739:4, 1739:14,

1739:16, 1741:25,

1742:8, 1747:37,

1751:12, 1752:4,

1754:18, 1754:40,

1755:1, 1757:23,

1757:26, 1757:31,

1768:22, 1771:43,

1772:45, 1773:1,

1786:3, 1786:8,

1786:19, 1786:21,

1786:31, 1789:18,

1789:19, 1797:12,

1798:6, 1799:10,

1799:12, 1799:13,

1799:29, 1800:6,

1801:35, 1801:40,

1803:47

community-based [7]

- 1738:32, 1739:4,

1752:4, 1754:18,

1757:23, 1797:12,

1801:40

Community-based [2]

- 1758:45, 1759:7

companion [1] -

1777:44

Company [1] - 1737:8

comparable [3] -

1735:24, 1736:21,

1798:14

comparative [1] -

1723:41

compare [4] -

1730:28, 1744:29,

1747:40, 1747:45

compared [5] -

1728:47, 1748:1,

1797:45, 1798:24,

1801:44

compares [1] -

1730:40

comparing [1] -

1761:37

comparison [4] -

1723:47, 1734:47,

1736:6, 1748:3

comparisons [2] -

1747:30, 1785:47

compatibility [1] -

1767:42

compatible [1] -

1774:36

competing [1] -

1786:30

complaint [1] -

1788:19

Complaints [1] -

1771:21

complement [1] -

1782:7

complemented [1] -

1777:29

complete [1] -

1717:25

completed [5] -

1719:8, 1719:13,

1793:41, 1793:47,

1795:12

completely [2] -

1719:1, 1720:19

completeness [1] -

1783:7

completing [1] -

1737:21

complex [20] -

1709:36, 1720:18,

1721:39, 1726:11,

1726:13, 1730:9,

1741:42, 1743:42,

1750:32, 1760:13,

1760:43, 1763:33,

1779:26, 1780:13,

1781:10, 1783:4,

1785:1, 1796:11,

1797:3, 1797:23

complexities [1] -

1796:8

complexity [8] -

1700:20, 1735:32,

1770:10, 1790:31,

1796:5, 1796:33,

1797:7, 1800:45

compliance [1] -

1698:2

component [2] -

1752:2, 1774:33

components [3] -

1721:11, 1752:9,

1799:39

comprehensive [4] -

1719:21, 1723:14,

1723:19, 1778:11

compromised [1] -

1771:18

compromises [1] -

1758:20

compulsorily [1] -

1758:29

compulsory [1] -

1758:28

concentrate [2] -

1723:4, 1760:36

concentrating [1] -

1715:46

concept [2] - 1749:11,

1784:44

concepts [1] -

1704:41

conceptually [1] -

1725:1

concern [9] - 1705:32,

1705:43, 1706:24,

1732:36, 1738:39,

1739:45, 1749:13,

1771:36, 1771:39

concerned [5] -

1706:2, 1706:3,

1744:25, 1744:27,

1748:18

concerning [2] -

1764:10, 1764:28

concerns [6] -

1712:13, 1712:40,

1716:42, 1727:42,

1734:3, 1735:15

concise [1] - 1762:46

concluded [1] -

1772:1

conclusion [4] -

1698:47, 1699:5,

1701:39, 1704:45

conditions [5] -

1760:26, 1760:29,

1764:6, 1766:36,

1798:42

conducted [1] -

1701:28

confidence [4] -

1732:41, 1733:34,

1786:21, 1799:30

confident [1] -

1730:20

configured [1] -

1753:46

confirm [4] - 1712:37,

1756:31, 1760:33,

1792:44

conflating [1] - 1708:7

conflation [1] -

1783:31

conflict [1] - 1781:18

confounding [1] -

1708:6

confused [1] -

1788:21

confusion [2] -

1788:11, 1788:15

conjunction [2] -

1761:44, 1763:25

connected [4] -

1722:20, 1762:24,

1763:32, 1791:31

connection [1] -

1800:15

connections [1] -

1767:22

conscious [3] -

1777:12, 1777:14,

1802:9

consensus [1] -

1770:43

consequence [1] -

1783:26

consequences [2] -

1729:4, 1743:33

consider [3] -

1703:28, 1712:21,

1749:7

considerable [4] -

1716:9, 1764:10,

1764:28, 1771:30

consideration [4] -

1746:3, 1746:6,

1762:5, 1766:44

considerations [3] -

1709:1, 1762:8,

1795:25

considered [3] -

1745:12, 1751:13,

1787:28

considering [5] -

1701:30, 1755:2,

1766:19, 1797:35,

1797:38

consistency [1] -

1733:14

consistent [8] -

1702:33, 1720:23,

1732:16, 1732:19,

1759:39, 1760:47,

1766:25, 1803:40

consistently [2] -

1702:41, 1788:38

Constitution [2] -

1698:7, 1698:17

constraints [5] -

1722:46, 1727:41,

1732:11, 1781:41,

1786:34

constructed [1] -

1752:26

construction [1] -

1741:20

consult [1] - 1698:12

consultations [1] -

1801:35

.25/07/2019 (18)


7

consumer [6] -

1721:4, 1761:16,

1781:41, 1788:36,

1789:12, 1796:37

consumers [15] -

1704:35, 1704:46,

1723:6, 1756:37,

1757:4, 1757:6,

1758:16, 1758:29,

1758:46, 1759:10,

1759:14, 1761:43,

1781:40, 1783:24,

1788:18

Consumers [1] -

1758:16

consumers' [1] -

1771:5

contact [4] - 1726:3,

1727:16, 1727:25,

1734:21

contacted [1] -

1782:15

contacts [1] - 1747:37

contemporary [3] -

1700:21, 1754:23,

1798:33

contest [1] - 1790:22

context [8] - 1702:28,

1725:5, 1727:12,

1732:20, 1766:9,

1766:23, 1772:12,

1791:11

contexts [1] - 1709:45

continually [1] -

1702:6

continue [7] - 1712:8,

1734:31, 1760:17,

1760:30, 1765:33,

1768:13, 1797:8

continued [5] -

1738:16, 1742:30,

1751:22, 1771:31,

1778:25

continues [1] -

1761:26

continuing [1] -

1791:6

continuity [5] -

1771:42, 1773:19,

1783:21, 1783:24,

1783:46

continuous [2] -

1788:12, 1788:16

continuum [3] -

1714:39, 1714:43,

1792:3

contracts [2] -

1743:19, 1749:43

contrast [1] - 1727:45

contribute [2] -

1741:45, 1769:15

contributes [2] -

1701:14, 1711:19

contribution [1] -

1802:46

contributions [1] -

1788:32

control [5] - 1710:2,

1710:3, 1727:22,

1750:4, 1753:21

controlled [1] -

1703:10

convenient [3] -

1736:29, 1755:28,

1773:27

conveniently [1] -

1773:38

conversation [3] -

1794:7, 1795:17,

1798:3

conversations [3] -

1711:30, 1728:13,

1771:21

convey [1] - 1799:9

coordinate [2] -

1701:5, 1790:2

coordinated [3] -

1701:4, 1707:11,

1763:5

coordination [1] -

1762:38

Coordination [1] -

1756:16

cope [1] - 1771:32

core [5] - 1754:39,

1755:13, 1758:7,

1770:42, 1775:43

correct [28] - 1698:24,

1698:25, 1713:17,

1713:21, 1713:41,

1714:5, 1737:13,

1737:28, 1737:38,

1740:16, 1752:32,

1752:45, 1754:16,

1755:45, 1756:44,

1756:45, 1761:4,

1761:39, 1768:32,

1771:12, 1775:38,

1776:10, 1789:26,

1789:28, 1794:18,

1794:19, 1794:47,

1797:41

corrections [1] -

1803:6

corridor [1] - 1752:39

corridors [4] -

1757:19, 1764:42,

1776:25, 1777:4

cost [8] - 1703:7,

1706:36, 1728:38,

1728:46, 1729:1,

1757:28, 1770:10,

1774:41

cost-effective [1] -

1774:41

cost-effectively [1] -

1757:28

costed [1] - 1745:17

costing [1] - 1796:35

costs [9] - 1699:43,

1700:3, 1724:42,

1729:4, 1746:28,

1746:32, 1746:40,

1746:44, 1774:4

Counsel [1] - 1696:33

counsel [1] - 1764:18

Counselling [1] -

1713:33

counter [1] - 1799:5

counterproductive [1]

- 1789:22

country [2] - 1752:14,

1796:45

couple [7] - 1744:13,

1769:24, 1773:37,

1775:16, 1776:33,

1783:36, 1786:23

course [15] - 1703:9,

1703:42, 1704:5,

1706:34, 1717:13,

1718:11, 1739:44,

1764:35, 1772:15,

1779:12, 1784:3,

1784:10, 1789:14,

1800:34, 1803:7

cousin [1] - 1747:5

cover [4] - 1703:7,

1724:42, 1734:9,

1781:15

coverage [1] -

1739:29

covered [5] - 1722:29,

1734:10, 1762:27,

1778:14, 1799:20

covering [2] -

1734:33, 1766:39

covers [3] - 1742:44,

1742:45, 1766:33

CPI [2] - 1746:35

create [6] - 1710:9,

1768:2, 1773:18,

1780:23, 1788:11,

1788:20

created [5] - 1701:8,

1716:23, 1780:12,

1783:33, 1800:25

creates [1] - 1701:15

creating [1] - 1757:22

creation [3] - 1775:18,

1776:32, 1786:43

credit [1] - 1716:20

Crisis [1] - 1731:5

crisis [3] - 1739:14,

1754:47, 1771:39

critical [18] - 1757:8,

1760:10, 1761:33,

1763:14, 1763:36,

1773:13, 1775:32,

1776:1, 1782:18,

1786:32, 1789:44,

1790:33, 1791:37,

1795:41, 1799:2,

1802:17, 1803:13,

1803:15

Critical [1] - 1713:27

criticality [1] -

1780:47

critically [1] - 1789:11

criticism [2] -

1749:26, 1778:29

Cross [1] - 1737:31

cross [9] - 1711:16,

1724:46, 1725:4,

1725:21, 1725:39,

1725:41, 1726:27,

1777:15, 1800:20

cross-government [2]

- 1711:16, 1800:20

cross-reference [1] -

1777:15

cross-subsidisation

[4] - 1724:46, 1725:4,

1725:39, 1725:41

cross-subsidise [2] -

1725:21, 1726:27

crystal [1] - 1793:5

cultural [1] - 1772:34

culture [1] - 1771:6

current [15] - 1699:13,

1699:29, 1699:47,

1709:14, 1710:47,

1714:15, 1715:38,

1720:36, 1737:15,

1756:30, 1761:37,

1767:7, 1770:2,

1795:38, 1796:1

custodianship [1] -

1775:22

cycle [6] - 1745:20,

1757:22, 1761:25,

1776:40, 1785:10,

1786:46

cycles [2] - 1707:18,

1785:15

CYMHS [2] - 1701:7,

1701:8

D

daily [1] - 1801:36

danger [1] - 1739:40

dangerous [1] -

1700:44

dashboard [3] -

1723:19, 1723:36,

1735:20

dashboards [1] -

1723:34

Data [1] - 1760:5

data [60] - 1699:38,

1700:7, 1700:9,

1700:13, 1700:21,

1704:2, 1704:4,

1704:6, 1704:9,

1704:10, 1705:19,

1721:47, 1722:10,

1722:11, 1723:14,

1723:41, 1751:22,

1761:17, 1768:44,

1773:23, 1773:31,

1773:32, 1773:36,

1773:38, 1773:43,

1774:15, 1774:18,

1774:21, 1774:28,

1774:32, 1774:38,

1774:46, 1775:3,

1775:5, 1775:22,

1775:23, 1775:26,

1775:30, 1775:36,

1775:43, 1776:4,

1780:9, 1780:29,

1781:45, 1781:47,

1785:27, 1785:30,

1791:14, 1791:18,

1791:40, 1794:25,

1794:39, 1802:27,

1802:45, 1803:3,

1803:5, 1803:6,

1803:40

datasets [2] - 1711:31,

1803:40

date [2] - 1713:47,

1779:14

days [1] - 1780:44

de [5] - 1738:31,

1738:36, 1738:47,

1748:29, 1786:2

de-

institutionalisation

[4] - 1738:31,

1738:36, 1738:47,

1786:2

de-prioritise [1] -

1748:29

deal [10] - 1739:47,

1740:5, 1749:17,

.25/07/2019 (18)


8

1753:46, 1754:10,

1764:19, 1778:30,

1778:46, 1784:42,

1795:8

dealing [4] - 1741:25,

1754:6, 1755:9,

1796:8

deals [1] - 1718:35

dealt [2] - 1745:23,

1785:26

death [1] - 1739:43

debate [6] - 1701:44,

1702:19, 1702:20,

1704:15, 1704:20,

1708:18

debates [1] - 1702:34

debilitating [1] -

1700:44

decade [1] - 1770:36

decades [1] - 1736:15

decision [6] -

1715:28, 1753:14,

1753:27, 1777:26,

1783:39, 1785:9

decision-making [2] -

1783:39, 1785:9

decisions [5] -

1706:22, 1708:46,

1753:23, 1764:33,

1799:10

declined [1] - 1781:40

decreased [1] -

1716:10

decreasing [1] -

1757:37

dedicated [2] -

1757:5, 1775:19

dedication [1] -

1741:26

deep [6] - 1748:23,

1774:10, 1788:34,

1790:16, 1796:46

deeper [4] - 1701:27,

1702:44, 1778:24,

1778:38

deeply [2] - 1789:33,

1791:30

deficit [3] - 1702:19,

1703:35, 1712:33

deficits [1] - 1727:41

define [2] - 1707:25,

1796:38

defined [3] - 1749:35,

1749:46, 1768:22

defining [5] - 1707:25,

1707:30, 1775:44,

1778:5, 1779:39

definitely [2] -

1748:13, 1786:30

definition [1] -

1789:16

delayed [1] - 1781:41

delegate [3] - 1738:9,

1738:11, 1738:14

deliberations [1] -

1786:18

deliver [15] - 1699:44,

1700:28, 1703:17,

1703:18, 1711:18,

1715:42, 1728:39,

1741:18, 1743:1,

1747:2, 1751:42,

1760:30, 1776:37,

1778:11, 1789:6

deliverable [1] -

1801:18

deliverables [2] -

1721:43, 1783:4

delivered [8] -

1708:45, 1729:46,

1751:44, 1760:15,

1760:19, 1761:20,

1761:24, 1788:38

delivering [8] -

1715:41, 1728:28,

1728:46, 1729:1,

1742:43, 1763:21,

1771:3, 1781:22

delivery [22] -

1701:33, 1701:47,

1703:13, 1703:43,

1704:24, 1704:29,

1706:47, 1708:17,

1708:46, 1710:27,

1714:36, 1729:5,

1743:20, 1747:21,

1752:15, 1754:38,

1763:38, 1787:32,

1787:36, 1787:37,

1797:12, 1800:17

demand [40] - 1699:7,

1699:15, 1699:21,

1699:30, 1700:5,

1700:11, 1700:16,

1700:20, 1701:4,

1705:8, 1705:23,

1729:9, 1729:12,

1729:14, 1729:42,

1730:25, 1730:47,

1742:27, 1742:31,

1758:14, 1764:1,

1764:10, 1764:29,

1764:38, 1765:5,

1765:24, 1770:15,

1771:17, 1771:29,

1771:33, 1772:5,

1772:11, 1772:18,

1772:30, 1776:8,

1778:18, 1794:3,

1801:36, 1802:16

demands [2] -

1741:42, 1745:39

demarc [1] - 1728:24

dementia [1] - 1734:3

demographic [2] -

1700:22, 1757:17

demographics [2] -

1700:1, 1764:43

demonstrate [2] -

1699:14, 1707:20

denied [1] - 1705:21

department [2] -

1724:37, 1771:35

Department [147] -

1699:6, 1699:15,

1699:20, 1699:32,

1699:41, 1699:43,

1700:14, 1701:6,

1701:9, 1701:12,

1701:19, 1701:33,

1701:37, 1701:42,

1701:43, 1701:45,

1702:13, 1702:22,

1702:30, 1702:35,

1703:11, 1703:15,

1703:38, 1703:45,

1704:12, 1704:17,

1704:19, 1704:21,

1704:25, 1705:39,

1705:46, 1707:3,

1709:6, 1712:38,

1712:41, 1716:23,

1717:18, 1717:46,

1720:3, 1721:3,

1722:24, 1727:16,

1728:23, 1729:38,

1731:5, 1732:27,

1732:36, 1734:32,

1736:9, 1737:34,

1737:42, 1737:46,

1738:20, 1738:27,

1738:28, 1738:46,

1739:1, 1739:45,

1740:39, 1741:12,

1743:44, 1744:9,

1744:16, 1744:20,

1744:26, 1744:30,

1744:33, 1744:35,

1745:6, 1745:23,

1745:24, 1745:33,

1745:34, 1745:36,

1745:41, 1746:1,

1746:4, 1746:5,

1752:30, 1752:33,

1753:1, 1753:6,

1753:12, 1753:40,

1753:43, 1753:45,

1754:3, 1754:10,

1754:42, 1754:45,

1755:7, 1755:9,

1755:41, 1756:2,

1756:7, 1756:11,

1756:16, 1760:34,

1760:37, 1761:7,

1761:31, 1762:19,

1762:28, 1763:15,

1763:25, 1764:46,

1766:1, 1770:19,

1772:4, 1772:9,

1772:36, 1772:39,

1775:8, 1775:20,

1777:2, 1777:41,

1778:26, 1778:34,

1782:17, 1782:32,

1782:44, 1783:2,

1784:24, 1784:30,

1785:25, 1786:36,

1787:25, 1789:3,

1789:34, 1790:2,

1791:10, 1791:22,

1791:38, 1791:47,

1792:11, 1792:24,

1794:13, 1794:15,

1794:20, 1794:22,

1794:38, 1795:22,

1795:23, 1795:44,

1796:16, 1797:34,

1803:25

Department's [10] -

1699:35, 1700:11,

1704:34, 1709:17,

1709:20, 1765:3,

1790:39, 1791:1,

1791:5, 1791:24

Departmental [2] -

1699:33, 1732:5

Departments [7] -

1729:11, 1731:22,

1744:11, 1794:28,

1794:32, 1794:35,

1795:8

dependencies [1] -

1799:32

dependency [1] -

1715:3

dependent [2] -

1744:6, 1748:40

depicted [1] - 1766:40

depressive [1] -

1798:43

depth [1] - 1747:19

Deputy [2] - 1756:10,

1756:15

deputy [2] - 1737:41,

1756:6

descending [1] -

1773:28

describe [9] -

1714:39, 1720:44,

1733:6, 1733:7,

1740:8, 1744:44,

1747:18, 1778:10,

1783:33

described [10] -

1698:16, 1701:46,

1707:2, 1710:28,

1720:36, 1726:28,

1737:26, 1760:10,

1760:11, 1766:26

description [4] -

1735:37, 1765:28,

1766:46, 1769:12

design [17] - 1701:20,

1703:29, 1708:47,

1709:22, 1709:28,

1710:11, 1710:27,

1761:19, 1761:41,

1761:42, 1762:4,

1781:12, 1787:35,

1796:15, 1796:16,

1796:44, 1803:32

designed [7] -

1708:26, 1731:41,

1742:28, 1754:2,

1760:46, 1777:40,

1797:19

designing [2] -

1797:15, 1802:30

desirability [1] -

1800:4

desire [1] - 1706:26

despite [3] - 1770:34,

1784:26, 1790:31

detail [11] - 1715:18,

1719:1, 1721:28,

1727:39, 1728:1,

1737:40, 1738:5,

1738:21, 1767:37,

1768:12, 1797:36

detailed [3] - 1779:9,

1779:17, 1786:36

determinants [2] -

1766:18, 1798:27

determination [1] -

1751:33

determine [2] -

1700:35, 1744:5

determined [2] -

1740:40, 1793:21

detract [1] - 1770:21

develop [7] - 1721:18,

1765:33, 1776:16,

1777:18, 1782:12,

1782:44, 1788:36

developed [11] -

1717:14, 1718:47,

1740:25, 1745:17,

1749:9, 1749:11,

1750:22, 1755:3,

1771:39, 1782:27

.25/07/2019 (18)


9

developing [11] -

1707:5, 1719:20,

1731:7, 1739:8,

1740:4, 1774:7,

1782:28, 1782:38,

1789:11, 1793:30,

1802:2

Development [1] -

1756:11

development [12] -

1737:22, 1742:27,

1761:41, 1776:31,

1778:22, 1787:41,

1788:28, 1791:31,

1791:42, 1792:12,

1802:13, 1802:33

developments [5] -

1751:11, 1755:12,

1774:43, 1775:16,

1787:46

develops [1] - 1760:18

devolved [7] -

1701:33, 1702:38,

1702:39, 1704:23,

1774:33, 1791:34,

1791:36

devoted [1] - 1783:10

DHHS [8] - 1700:4,

1712:5, 1727:11,

1728:45, 1745:30,

1765:20, 1772:17,

1803:5

DHHS.0002.0003.

1073 [1] - 1765:14

dialogue [4] -

1711:45, 1711:46,

1736:9, 1745:6

difference [6] -

1716:15, 1774:22,

1779:46, 1780:38,

1791:36, 1802:21

differences [1] -

1790:31

different [43] -

1703:34, 1708:40,

1708:41, 1720:27,

1721:5, 1725:42,

1732:28, 1742:47,

1743:16, 1745:23,

1751:4, 1752:9,

1763:11, 1763:47,

1766:44, 1766:45,

1767:40, 1774:1,

1774:3, 1778:14,

1779:43, 1781:47,

1783:15, 1783:43,

1788:2, 1788:32,

1789:20, 1789:37,

1790:9, 1790:15,

1790:17, 1790:25,

1792:35, 1794:6,

1795:28, 1795:34,

1797:40, 1799:11,

1799:30, 1801:44,

1802:19

differently [2] -

1776:46, 1786:13

differing [2] - 1763:39,

1763:40

difficult [18] - 1706:4,

1720:30, 1724:30,

1724:31, 1725:28,

1727:1, 1728:26,

1729:27, 1729:29,

1730:41, 1731:14,

1731:30, 1734:2,

1743:40, 1749:15,

1750:28, 1800:26

difficulties [2] -

1749:34, 1779:25

difficulty [1] - 1726:40

Diploma [2] - 1713:23,

1713:33

direct [5] - 1699:3,

1714:47, 1743:11,

1766:47, 1781:18

directed [3] - 1698:18,

1708:33, 1708:45

directing [1] - 1783:11

direction [9] -

1711:33, 1740:24,

1742:35, 1762:46,

1763:26, 1766:27,

1768:12, 1777:14,

1777:28

directly [5] - 1699:25,

1701:25, 1739:1,

1763:38, 1778:18

Director [9] - 1715:29,

1734:5, 1737:43,

1737:44, 1738:19,

1738:23, 1738:45,

1740:45, 1756:1

director [1] - 1737:41

Director-General [2] -

1738:45, 1740:45

Directorate [1] -

1719:22

directorates [1] -

1718:47

Directors [2] -

1716:31, 1737:9

disability [2] -

1740:41, 1769:1

disabled [1] - 1738:43

disadvantage [1] -

1747:15

disagree [3] -

1758:23, 1758:34,

1759:18

disagreement [2] -

1704:22, 1790:28

discern [2] - 1706:4,

1708:25

discharge [5] -

1698:18, 1730:11,

1730:13, 1757:30,

1758:42

discharged [1] -

1757:40

discharging [3] -

1697:41, 1730:20,

1730:26

discipline [1] -

1782:46

disclosing [1] -

1797:46

disclosure [1] -

1738:41

discount [2] - 1786:9,

1798:42

discounting [1] -

1773:6

discrepancy [1] -

1729:4

discrete [1] - 1731:3

discrimination [4] -

1773:5, 1780:11,

1798:39

discuss [1] - 1772:15

discussed [5] -

1764:6, 1764:18,

1764:27, 1771:9,

1793:6

discussing [1] -

1724:23

discussion [5] -

1716:42, 1720:8,

1728:6, 1784:34,

1793:25

discussions [8] -

1724:16, 1743:28,

1745:41, 1745:42,

1750:40, 1792:7,

1793:16, 1793:18

disease [4] - 1790:43,

1797:20, 1797:22,

1797:23

disentangle [1] -

1743:40

disincentive [1] -

1726:31

disorder [1] - 1798:42

disorders [1] -

1798:43

disparate [1] - 1796:5

disparity [1] - 1801:41

dispersed [1] -

1776:46

displayed [1] -

1766:41

dissimilar [1] -

1717:25

distance [1] - 1708:36

distinguish [1] -

1790:5

distinguished [1] -

1779:29

distortion [1] -

1780:24

distress [1] - 1776:27

distributed [1] -

1788:10

distribution [1] -

1765:24

distrust [1] - 1701:15

disturbed [1] - 1754:7

dive [4] - 1748:23,

1778:24, 1778:39,

1779:17

diversity [1] - 1717:36

diverting [1] - 1757:25

dividends [1] -

1746:38

divides [1] - 1728:26

division [2] - 1704:20,

1796:26

document [20] -

1705:40, 1705:47,

1712:11, 1718:20,

1740:26, 1765:10,

1765:13, 1765:16,

1765:46, 1766:2,

1766:13, 1768:36,

1770:30, 1777:11,

1777:12, 1777:22,

1777:27, 1777:40,

1779:2

documents [6] -

1706:19, 1718:17,

1778:1, 1778:14,

1778:45, 1779:36

domain [2] - 1729:37,

1778:21

done [24] - 1699:6,

1709:6, 1711:4,

1711:7, 1712:7,

1716:10, 1716:16,

1723:10, 1727:15,

1739:27, 1740:37,

1741:17, 1747:40,

1750:18, 1753:11,

1754:28, 1763:3,

1772:4, 1778:41,

1783:36, 1801:15,

1802:34, 1803:10

door' [1] - 1757:33

dot [2] - 1767:27,

1767:47

down [18] - 1709:10,

1709:12, 1711:34,

1714:24, 1714:41,

1721:12, 1724:22,

1726:44, 1759:35,

1760:2, 1760:6,

1763:37, 1763:44,

1766:9, 1767:26,

1767:46, 1773:24,

1783:4

Dr [1] - 1696:28

draw [2] - 1743:14,

1744:41

drawing [3] - 1738:35,

1761:42, 1762:3

drawn [1] - 1785:29

drive [10] - 1705:28,

1709:25, 1710:15,

1719:4, 1735:33,

1739:34, 1749:27,

1781:10, 1801:27

driven [5] - 1709:1,

1722:24, 1749:12,

1762:45, 1803:45

driver [2] - 1709:44,

1718:16

drivers [3] - 1717:40,

1769:32, 1778:24

driving [3] - 1739:19,

1757:24, 1757:29

drove [3] - 1719:17,

1738:36, 1740:23

Duckett [5] - 1701:43,

1775:17, 1790:41,

1791:10, 1791:30

due [4] - 1757:40,

1770:9, 1781:41,

1803:37

duplication [1] -

1700:9

duration [1] - 1744:28

during [3] - 1702:4,

1715:24, 1738:44

duties [1] - 1698:18

duty [3] - 1724:25,

1760:44, 1761:10

E

early [9] - 1716:24,

1736:28, 1749:11,

1759:34, 1789:40,

1793:47, 1797:14,

1798:8, 1799:28

easier [1] - 1724:11

easily [3] - 1709:39,

1717:23, 1773:39

easy [6] - 1733:39,

1748:37, 1750:30,

1754:31, 1774:21,

.25/07/2019 (18)


10

1774:27

eating [1] - 1730:17

EBA [1] - 1746:33

Economic [1] -

1756:11

economic [1] - 1769:3

Economics [1] -

1737:7

economy [1] -

1697:47

ED [1] - 1723:36

educate [3] - 1720:31,

1734:1, 1739:46

educating [3] -

1720:11, 1720:14,

1733:16

education [2] -

1781:34, 1803:5

Education [2] -

1756:6, 1756:7

educational [1] -

1781:35

effect [11] - 1702:25,

1707:33, 1709:24,

1773:6, 1774:3,

1776:4, 1779:37,

1783:19, 1783:33,

1784:20, 1794:43

effective [7] - 1697:40,

1718:9, 1722:19,

1731:38, 1774:41,

1785:6, 1786:45

effectively [8] -

1700:36, 1702:23,

1703:24, 1730:46,

1733:23, 1757:28,

1771:33, 1801:11

effectiveness [3] -

1698:1, 1705:29,

1733:21

efficiency [3] -

1697:47, 1746:38,

1747:1

efficient [2] - 1697:39,

1757:14

effort [4] - 1763:28,

1768:24, 1777:35,

1781:18

efforts [3] - 1774:35,

1788:13, 1788:16

EFT [5] - 1724:26,

1725:31, 1725:45,

1726:4, 1729:16

eight [4] - 1715:24,

1794:17, 1794:24,

1794:36

eight-hour [2] -

1794:24, 1794:36

either [14] - 1697:46,

1708:43, 1730:31,

1743:37, 1745:15,

1750:20, 1751:11,

1753:29, 1758:34,

1770:27, 1774:34,

1774:35, 1781:14,

1798:44

elaborate [5] -

1705:31, 1725:43,

1731:15, 1757:12,

1759:38

election [2] - 1785:10,

1785:15

elective [1] - 1772:38

elements [7] -

1699:36, 1742:23,

1754:39, 1778:14,

1789:20, 1790:25,

1799:33

elicit [1] - 1784:45

elsewhere [2] -

1710:43, 1719:18

elucidates [1] -

1773:16

embed [1] - 1792:6

embedded [3] -

1792:22, 1793:43,

1801:7

embodied [2] -

1771:9, 1771:19

emerge [2] - 1707:17

emerged [1] - 1770:38

emergency [3] -

1753:26, 1757:24,

1771:35

Emergency [46] -

1716:23, 1721:2,

1729:11, 1731:5,

1731:21, 1732:27,

1732:36, 1743:44,

1744:9, 1744:11,

1744:16, 1744:20,

1744:26, 1744:30,

1744:32, 1744:34,

1752:30, 1752:33,

1753:1, 1753:6,

1753:12, 1753:40,

1753:42, 1753:45,

1754:3, 1754:10,

1754:42, 1754:45,

1755:7, 1755:9,

1772:39, 1782:17,

1792:11, 1792:24,

1794:13, 1794:14,

1794:15, 1794:20,

1794:22, 1794:28,

1794:32, 1794:35,

1794:37, 1794:45,

1795:8, 1795:44

emerging [1] -

1767:33

eminent [1] - 1752:14

emphasis [5] -

1771:1, 1780:16,

1780:20, 1786:3,

1791:26

emphasised [1] -

1747:12

employ [1] - 1726:12

employed [1] - 1743:9

employees [2] -

1714:42, 1738:26

empowers [1] -

1771:7

enable [12] - 1739:10,

1761:21, 1761:25,

1769:14, 1773:37,

1777:41, 1778:38,

1781:1, 1782:40,

1783:30, 1783:40,

1796:30

enablers [1] - 1760:11

enables [1] - 1747:45

enabling [1] - 1760:28

enact [1] - 1785:16

encapsulate [3] -

1758:7, 1761:28,

1762:28

encapsulates [1] -

1761:6

encountered [1] -

1772:24

encouraged [1] -

1734:5

end [8] - 1711:21,

1714:39, 1725:14,

1769:8, 1769:10,

1779:15, 1785:22,

1793:41

endeavour [3] -

1764:16, 1764:20,

1775:2

endeavouring [1] -

1769:21

endurance [1] -

1800:16

endure [1] - 1800:38

enduring [1] - 1800:14

engage [7] - 1716:16,

1736:9, 1746:9,

1764:46, 1767:9,

1785:31, 1802:19

engaged [5] -

1711:45, 1711:46,

1716:41, 1733:45,

1801:16

engagement [4] -

1759:34, 1790:17,

1791:7, 1803:19

engages [1] - 1765:30

engender [1] -

1783:46

enhanced [1] -

1781:35

enhancement [1] -

1742:4

enhancements [3] -

1742:15, 1754:27,

1754:37

enormous [4] -

1739:44, 1741:42,

1796:19, 1796:37

enshrine [1] - 1708:37

ensure [7] - 1718:37,

1749:22, 1749:30,

1749:44, 1765:21,

1768:24, 1777:3

ensuring [1] - 1777:19

entail [1] - 1790:10

entering [2] - 1726:11,

1757:47

entire [3] - 1763:44,

1767:9, 1767:14

entirely [4] - 1703:10,

1750:29, 1780:27,

1781:7

entities [2] - 1760:35,

1761:12

entitled [1] - 1765:10

entity [1] - 1697:46

entrench [1] - 1780:10

entrenched [1] -

1757:47

environment [10] -

1701:33, 1721:24,

1726:23, 1731:36,

1731:46, 1731:47,

1736:3, 1760:18,

1786:9, 1800:44

environments [2] -

1785:43, 1798:32

episode [2] - 1758:18,

1758:41

episodic [1] - 1782:4

equally [2] - 1796:11,

1803:18

equation [1] - 1706:28

equivalent [1] -

1747:24

especially [2] -

1709:36, 1716:22

essential [3] -

1752:12, 1774:32,

1775:31

essentially [3] -

1724:14, 1726:16,

1771:16

establish [1] - 1739:4

established [6] -

1736:8, 1748:22,

1749:10, 1749:22,

1761:2, 1780:29

establishing [3] -

1703:46, 1800:5,

1802:3

establishment [3] -

1738:32, 1739:13,

1739:16

esteem [3] - 1798:24,

1798:25, 1799:4

estimate [1] - 1707:40

estimated [1] -

1769:35

Estimates [2] -

1698:9, 1698:10

estimation [3] -

1703:15, 1709:5,

1710:16

et [3] - 1716:29,

1734:3, 1752:6

Ethical [1] - 1713:39

evaluate [2] - 1705:3,

1705:29

evaluates [1] -

1762:19

evaluation [4] -

1711:7, 1783:38,

1783:41, 1803:24

evaluations [1] -

1711:23

event [2] - 1726:40,

1753:33

events [7] - 1735:24,

1739:24, 1749:2,

1780:23, 1780:25,

1790:37, 1790:40

evidence [53] -

1699:28, 1709:32,

1709:45, 1709:47,

1713:6, 1755:24,

1757:6, 1758:12,

1758:37, 1759:12,

1759:39, 1760:17,

1761:17, 1761:25,

1761:42, 1762:31,

1764:9, 1764:27,

1771:15, 1773:17,

1775:7, 1775:28,

1775:47, 1776:3,

1776:24, 1779:24,

1779:34, 1779:37,

1780:44, 1781:30,

1783:18, 1784:1,

1784:4, 1784:20,

1785:40, 1786:12,

1791:46, 1792:4,

1793:6, 1793:26,

1794:14, 1794:43,

1795:2, 1795:25,

1795:46, 1796:7,

1796:13, 1798:39,

.25/07/2019 (18)


11

1800:4, 1800:43,

1801:33, 1801:34,

1804:8

evidence-based [2] -

1759:12, 1784:1

evident [3] - 1780:19,

1798:27, 1798:29

evolve [2] - 1760:17,

1760:26

evolved [6] - 1719:27,

1723:1, 1723:29,

1736:16, 1736:17,

1742:30

evolving [2] - 1775:44,

1792:40

exacerbate [1] -

1770:27

exactly [3] - 1721:10,

1735:46, 1795:39

examination [4] -

1795:5, 1795:11,

1795:33, 1795:35

examine [3] - 1697:42,

1697:46, 1784:29

examined [4] -

1697:5, 1713:13,

1736:42, 1755:38

example [26] -

1706:13, 1706:41,

1707:36, 1708:10,

1710:43, 1710:46,

1712:10, 1720:14,

1720:46, 1725:1,

1726:43, 1728:44,

1731:4, 1733:29,

1738:42, 1743:43,

1753:2, 1753:33,

1770:24, 1777:32,

1780:22, 1789:18,

1793:10, 1801:18,

1802:5, 1802:34

examples [2] -

1710:41, 1800:25

exceed [1] - 1794:46

exceeded [1] -

1770:20

exceeding [1] -

1729:36

except [1] - 1729:10

exceptions [1] -

1774:27

excessive [1] -

1744:25

excused [3] - 1713:3,

1755:21, 1804:5

excuses [1] - 1774:40

Executive [15] -

1713:20, 1714:10,

1714:23, 1715:29,

1722:29, 1728:27,

1737:30, 1737:32,

1737:33, 1745:5,

1750:20, 1750:39,

1750:40, 1756:1,

1782:33

executive [18] -

1698:15, 1698:21,

1714:21, 1715:20,

1715:22, 1715:31,

1716:7, 1716:11,

1716:30, 1716:31,

1717:15, 1719:36,

1719:42, 1719:44,

1720:28, 1721:38,

1722:12, 1750:18

exercise [1] - 1796:12

exercises [1] -

1760:47

exhibited [1] - 1703:3

exist [3] - 1754:43,

1763:7, 1779:36

existing [9] - 1699:34,

1747:29, 1773:16,

1774:47, 1792:7,

1794:6, 1794:30,

1798:40, 1800:36

exists [1] - 1734:34

expanded [1] -

1742:30

expect [4] - 1705:9,

1712:44, 1721:4,

1763:11

expectation [3] -

1712:37, 1728:40,

1799:13

expectations [2] -

1793:27, 1798:33

expected [4] -

1728:39, 1789:6,

1793:41, 1793:46

expedite [1] - 1753:28

expend [1] - 1725:14

Expenditure [1] -

1741:37

expenditure [1] -

1746:23

expense [1] - 1780:16

experience [42] -

1697:25, 1702:15,

1703:37, 1704:26,

1707:15, 1708:31,

1713:46, 1714:9,

1714:13, 1714:16,

1714:29, 1715:30,

1715:36, 1717:6,

1717:9, 1717:46,

1718:3, 1718:28,

1720:39, 1723:9,

1723:32, 1727:12,

1731:16, 1732:26,

1733:27, 1733:28,

1737:26, 1737:36,

1738:35, 1744:41,

1746:47, 1747:23,

1748:9, 1748:13,

1748:31, 1749:8,

1756:37, 1759:15,

1781:42, 1789:31,

1791:21, 1801:36

experienced [2] -

1772:37, 1776:25

experiences [3] -

1720:22, 1720:26,

1720:35

experiencing [3] -

1715:39, 1762:47,

1766:35

expert [2] - 1773:15,

1796:11

expertise [6] -

1733:46, 1761:45,

1787:35, 1788:33,

1796:43, 1796:46

experts [2] - 1796:38,

1797:35

explain [4] - 1697:35,

1721:1, 1724:11,

1734:18

explained [2] -

1735:31, 1745:2

explicit [1] - 1792:29

explore [1] - 1798:35

exposed [1] - 1716:43

exposure [1] -

1714:17

express [6] - 1706:10,

1706:12, 1706:25,

1707:19, 1707:43

expressed [10] -

1704:17, 1705:44,

1705:45, 1706:18,

1706:37, 1706:43,

1706:44, 1708:1,

1708:13, 1712:14

expressing [3] -

1703:32, 1707:16,

1707:23

expression [2] -

1761:10, 1798:23

expressions [1] -

1779:30

extended [1] -

1754:40

extensive [6] -

1714:29, 1715:30,

1717:6, 1720:39,

1735:40, 1735:44

extent [18] - 1698:1,

1698:43, 1700:15,

1702:21, 1702:25,

1702:34, 1702:35,

1702:36, 1711:46,

1712:13, 1712:32,

1717:45, 1723:29,

1729:46, 1744:44,

1782:43, 1787:7,

1798:46

external [4] - 1697:26,

1722:16, 1748:21,

1748:26

extra [7] - 1716:29,

1725:27, 1726:24,

1746:19, 1776:35,

1794:24, 1794:31

extract [1] - 1774:21

extremely [3] -

1726:11, 1744:10,

1779:5

F

fabric [1] - 1798:30

faces [1] - 1701:13

facets [1] - 1781:15

facilitating [1] -

1791:42

facilities [7] - 1731:20,

1739:11, 1741:21,

1744:32, 1744:39,

1754:10, 1785:42

facility [1] - 1731:41

facing [1] - 1760:43

fact [17] - 1706:12,

1708:4, 1711:36,

1712:4, 1720:38,

1720:39, 1729:36,

1734:41, 1736:19,

1737:36, 1749:9,

1749:10, 1751:40,

1764:47, 1780:20,

1785:2, 1802:25

factor [2] - 1702:15,

1785:18

factoring [1] - 1787:46

factors [17] - 1701:29,

1701:31, 1701:32,

1721:31, 1738:36,

1760:10, 1767:33,

1769:43, 1770:9,

1776:28, 1776:30,

1785:45, 1786:19,

1791:18, 1797:47,

1798:3

fair [2] - 1779:29,

1793:29

Fairfax [1] - 1713:39

fairly [3] - 1716:9,

1720:23, 1732:40

falling [1] - 1763:2

falls [2] - 1735:5,

1798:31

familiar [4] - 1759:29,

1765:6, 1766:5,

1767:38

families [2] - 1700:45,

1761:14

Family [1] - 1782:35

family [2] - 1772:41,

1788:18

fantastic [2] -

1733:47, 1802:34

far [8] - 1710:16,

1723:31, 1764:20,

1786:41, 1786:46,

1787:11, 1793:37,

1794:44

fear [2] - 1733:32,

1733:33

feature [3] - 1703:9,

1704:26, 1704:27

featured [1] - 1717:29

features [2] - 1703:2,

1711:6

February [1] - 1715:32

Federal [1] - 1746:16

federal [1] - 1697:26

feed [1] - 1708:28

feedback [3] -

1761:24, 1771:22,

1794:8

fees [1] - 1728:42

Felicity [1] - 1713:10

FELICITY [1] -

1713:13

Fellow [1] - 1737:8

Fellowship [1] -

1713:39

Fels [1] - 1696:27

felt [2] - 1719:21,

1739:41

few [15] - 1699:14,

1699:24, 1727:19,

1734:39, 1774:27,

1779:42, 1780:44,

1781:9, 1781:17,

1786:43, 1795:7,

1795:37, 1798:20,

1800:3, 1800:32

fewer [1] - 1780:32

Fifth [3] - 1751:31,

1765:35, 1777:34

figure [1] - 1707:39

filed [1] - 1759:21

fill [1] - 1726:26

filling [1] - 1726:31

final [8] - 1706:12,

1708:2, 1708:5,

1708:18, 1732:10,

1737:41, 1802:23,

.25/07/2019 (18)


12

1804:3

finalised [1] - 1793:33

finally [8] - 1709:31,

1758:37, 1759:5,

1771:26, 1782:21,

1789:47, 1800:41,

1803:24

Finance [2] - 1707:10,

1737:47

Financial [1] -

1697:22

financial [5] -

1697:42, 1697:43,

1738:10, 1747:20,

1747:27

findings [6] - 1699:10,

1699:11, 1701:1,

1701:2, 1778:8,

1779:5

fine [2] - 1779:46,

1799:27

finish [4] - 1724:18,

1775:7, 1777:23,

1795:20

Fiona [1] - 1696:36

firearms [1] - 1739:42

firm [1] - 1752:10

first [40] - 1698:34,

1698:40, 1701:32,

1701:37, 1701:38,

1704:3, 1704:41,

1706:6, 1706:32,

1707:5, 1710:1,

1715:24, 1716:3,

1718:3, 1727:13,

1732:16, 1734:40,

1740:17, 1740:29,

1746:3, 1749:9,

1750:14, 1759:33,

1763:22, 1764:25,

1767:47, 1772:20,

1772:27, 1773:9,

1774:19, 1778:38,

1779:18, 1780:43,

1784:22, 1788:23,

1790:40, 1796:13,

1796:45, 1797:29,

1802:15

firstly [4] - 1714:35,

1737:5, 1750:8,

1785:6

fit [3] - 1709:12,

1788:42, 1797:16

fits [2] - 1701:19,

1789:21

five [12] - 1700:26,

1704:2, 1707:22,

1717:14, 1737:32,

1740:16, 1742:29,

1754:43, 1755:28,

1755:31, 1759:22,

1802:14

five-year [2] -

1717:14, 1802:14

flexibility [2] -

1709:44, 1789:16

flow [1] - 1795:42

flows [1] - 1795:25

focus [12] - 1709:42,

1738:4, 1739:23,

1742:2, 1758:15,

1764:45, 1768:27,

1775:26, 1787:17,

1789:5, 1790:38,

1792:11

focused [9] - 1700:38,

1706:36, 1708:32,

1711:26, 1734:44,

1748:13, 1748:15,

1766:39, 1803:14

focuses [2] - 1718:30,

1770:47

focusing [1] - 1725:40

follow [1] - 1755:16

followed [3] -

1717:11, 1732:38,

1752:11

Following [1] - 1789:1

following [3] -

1711:43, 1713:23,

1757:15

follows [1] - 1789:31

food [3] - 1730:17,

1743:19, 1743:20

force [1] - 1740:5

Forces [1] - 1799:44

forces [1] - 1739:19

forecasting [1] -

1773:32

forecasts [2] - 1724:8,

1765:5

foremost [3] - 1706:6,

1706:33, 1707:5

forensic [1] - 1742:21

foreshadowed [1] -

1778:40

form [3] - 1703:32,

1793:17, 1800:26

formal [2] - 1727:36,

1793:42

forms [1] - 1795:24

fortunate [1] - 1731:24

forward [13] -

1716:26, 1723:9,

1766:27, 1774:1,

1774:43, 1778:39,

1778:44, 1783:43,

1783:45, 1787:36,

1790:7, 1790:34,

1801:27

forward-looking [2] -

1783:43, 1783:45

foundation [2] -

1760:3, 1773:29

foundations [2] -

1765:22, 1780:9

four [8] - 1707:22,

1728:1, 1728:4,

1772:37, 1772:43,

1794:16, 1794:19,

1794:29

four-hour [1] -

1794:19

frail [1] - 1754:5

frame [3] - 1791:25,

1791:26, 1799:38

framework [65] -

1699:24, 1701:5,

1701:34, 1705:9,

1705:37, 1705:40,

1705:46, 1706:1,

1706:20, 1706:25,

1706:35, 1707:2,

1707:6, 1707:7,

1707:11, 1707:12,

1707:29, 1708:1,

1708:14, 1708:17,

1708:25, 1708:42,

1709:15, 1709:18,

1709:23, 1709:24,

1709:29, 1711:1,

1711:2, 1711:6,

1711:14, 1715:45,

1717:40, 1718:29,

1719:10, 1719:26,

1719:28, 1725:16,

1740:26, 1741:5,

1767:31, 1768:35,

1768:40, 1769:5,

1769:6, 1769:19,

1769:23, 1777:9,

1780:2, 1780:37,

1782:7, 1782:8,

1782:12, 1789:39,

1790:1, 1790:10,

1790:14, 1790:18,

1790:32, 1793:33,

1793:39, 1793:46,

1794:10

framework's [1] -

1736:7

frameworks [7] -

1706:18, 1710:32,

1723:29, 1751:2,

1751:3, 1768:39,

1789:47

frank [1] - 1702:29

Frankston [2] -

1731:26, 1734:25

frequently [1] -

1748:43

FRIDAY [1] - 1804:15

front [1] - 1799:22

fulcrum [1] - 1800:13

fulfil [1] - 1774:42

full [4] - 1702:28,

1729:46, 1745:17,

1753:19

Full [1] - 1737:20

full-blown [1] -

1745:17

Full-Time [1] -

1737:20

fully [6] - 1703:17,

1724:41, 1745:17,

1761:31, 1764:13,

1775:33

function [4] - 1697:46,

1703:37, 1792:9,

1803:21

functionality [1] -

1700:8

functioning [3] -

1760:21, 1760:23,

1802:30

functions [5] -

1697:41, 1698:19,

1761:33, 1787:39,

1789:34

fund [3] - 1708:44,

1746:43

fundamental [1] -

1803:31

fundamentally [2] -

1742:11, 1742:14

fundamentals [1] -

1803:41

funded [12] - 1703:17,

1728:37, 1734:19,

1745:8, 1751:16,

1752:13, 1762:20,

1767:1, 1777:4,

1777:5, 1789:5,

1793:40

Funding [2] - 1760:4,

1762:6

funding [104] -

1699:34, 1699:36,

1699:47, 1700:5,

1700:19, 1700:24,

1700:27, 1703:4,

1703:5, 1703:10,

1703:12, 1706:21,

1708:33, 1708:45,

1712:21, 1712:24,

1712:29, 1712:34,

1724:5, 1724:8,

1724:38, 1724:39,

1724:41, 1725:7,

1725:8, 1725:27,

1725:47, 1726:2,

1726:5, 1726:17,

1727:11, 1727:14,

1728:8, 1729:5,

1730:33, 1730:36,

1730:44, 1730:45,

1731:1, 1731:3,

1731:8, 1731:9,

1731:13, 1739:10,

1741:18, 1745:1,

1745:7, 1745:10,

1745:14, 1745:16,

1745:26, 1747:10,

1751:14, 1751:17,

1751:18, 1751:23,

1752:12, 1754:8,

1760:14, 1761:19,

1762:3, 1762:12,

1762:13, 1762:14,

1765:23, 1772:37,

1772:38, 1772:39,

1772:40, 1773:13,

1773:15, 1773:17,

1776:28, 1776:35,

1777:6, 1782:6,

1783:20, 1783:46,

1786:18, 1795:46,

1796:1, 1796:2,

1796:8, 1796:9,

1796:15, 1796:28,

1796:29, 1796:44,

1797:6, 1797:7,

1797:10, 1797:15,

1797:18, 1797:25,

1797:35, 1797:36,

1797:38, 1797:43,

1798:16, 1802:3,

1802:24, 1803:39

funding's [1] - 1796:3

funds [9] - 1702:23,

1702:26, 1703:6,

1703:12, 1725:14,

1725:15, 1739:11,

1743:34, 1745:32

furnished [1] -

1793:26

future [7] - 1699:30,

1750:4, 1751:13,

1751:14, 1757:10,

1764:7, 1803:32

G

gaining [1] - 1775:11

gap [11] - 1699:42,

1706:6, 1746:42,

1757:45, 1759:34,

1759:35, 1759:36,

1764:10, 1765:5,

1772:18

.25/07/2019 (18)


13

gaps [17] - 1699:35,

1701:8, 1743:35,

1748:38, 1758:3,

1758:4, 1759:22,

1759:32, 1759:43,

1760:3, 1761:38,

1764:28, 1767:13,

1770:37, 1773:29,

1774:40, 1798:28

gather [2] - 1774:32,

1775:30

gathering [5] -

1773:24, 1773:36,

1774:17, 1774:19,

1774:46

gazetted [2] - 1750:8,

1750:10

General [36] - 1697:2,

1697:7, 1697:12,

1697:20, 1697:22,

1697:36, 1697:38,

1698:4, 1698:14,

1698:23, 1702:18,

1702:20, 1704:16,

1704:17, 1704:21,

1728:44, 1738:45,

1740:45, 1765:2,

1765:17, 1769:31,

1771:46, 1772:1,

1772:29, 1773:30,

1774:22, 1775:27,

1778:8, 1779:34,

1781:39, 1782:22,

1782:34, 1784:23,

1789:47, 1791:35,

1794:8

general [10] - 1729:1,

1768:6, 1785:13,

1792:23, 1794:16,

1795:6, 1795:30,

1797:4, 1797:5,

1798:31

General's [7] -

1697:16, 1778:16,

1778:29, 1779:45,

1780:36, 1782:14,

1785:2

generally [13] -

1698:29, 1704:18,

1704:27, 1709:27,

1714:30, 1746:24,

1746:35, 1751:12,

1751:15, 1780:31,

1781:16, 1793:24,

1794:38

genuine [2] - 1783:40,

1784:5

geographic [2] -

1749:6, 1784:36

Georgina [1] -

1696:35

gist [2] - 1776:44,

1786:27

given [20] - 1702:25,

1705:10, 1709:24,

1710:29, 1710:47,

1712:13, 1712:28,

1714:20, 1716:12,

1721:32, 1734:24,

1736:29, 1769:42,

1771:15, 1779:24,

1782:36, 1787:45,

1797:22, 1800:24,

1803:1

Glenn [1] - 1762:32

goal [1] - 1768:30

goals [6] - 1740:11,

1740:15, 1740:20,

1740:27, 1740:29,

1751:37

govern [1] - 1734:42

Governance [2] -

1756:15, 1760:4

governance [32] -

1715:45, 1720:11,

1722:16, 1722:36,

1738:28, 1748:36,

1750:5, 1750:45,

1751:2, 1751:3,

1751:4, 1763:21,

1763:24, 1763:30,

1765:30, 1765:31,

1774:23, 1774:33,

1782:31, 1782:37,

1784:39, 1790:36,

1791:12, 1791:37,

1799:42, 1800:2,

1800:10, 1800:14,

1801:9, 1801:18,

1801:27

Government [9] -

1737:37, 1746:19,

1759:22, 1760:9,

1766:42, 1767:2,

1767:8, 1785:30,

1795:47

government [56] -

1697:27, 1698:15,

1698:24, 1698:27,

1698:30, 1699:32,

1702:29, 1704:28,

1705:36, 1706:13,

1708:17, 1709:11,

1709:22, 1709:28,

1710:3, 1710:29,

1711:16, 1712:22,

1712:23, 1712:32,

1712:39, 1717:23,

1724:16, 1737:22,

1738:45, 1740:32,

1745:14, 1746:9,

1746:11, 1746:12,

1747:14, 1750:11,

1759:22, 1760:40,

1760:44, 1760:46,

1761:7, 1762:12,

1763:27, 1764:33,

1766:27, 1768:11,

1770:19, 1772:31,

1773:30, 1773:42,

1777:29, 1777:41,

1778:37, 1781:29,

1783:35, 1785:20,

1786:4, 1786:5,

1800:6, 1800:20

government's [4] -

1705:47, 1709:13,

1717:21, 1724:29

Government's [6] -

1759:28, 1773:33,

1775:29, 1776:3,

1784:15, 1788:4

governments [2] -

1708:40, 1746:17

Graduate [1] -

1713:33

grant [3] - 1734:20,

1734:22, 1734:23

granted [1] - 1798:1

grants [2] - 1724:18,

1725:11

granularity [1] -

1773:29

graph [1] - 1766:41

graze [1] - 1735:12

great [9] - 1731:35,

1733:46, 1734:27,

1767:37, 1770:24,

1775:26, 1780:8,

1789:32

greater [4] - 1721:28,

1723:29, 1725:47,

1746:22

greatest [1] - 1768:25

Greaves [11] - 1697:2,

1697:7, 1697:35,

1698:47, 1700:32,

1701:24, 1703:31,

1710:19, 1710:23,

1713:3, 1713:6

GREAVES [1] - 1697:5

ground [4] - 1763:31,

1774:21, 1800:22,

1800:37

Group [3] - 1697:21,

1697:23, 1756:6

group [3] - 1720:47,

1727:7, 1803:4

groups [3] - 1720:6,

1742:22, 1761:16

growing [2] - 1730:47,

1752:36

growth [19] - 1705:8,

1730:33, 1730:36,

1730:45, 1752:37,

1752:38, 1757:19,

1764:39, 1764:41,

1770:16, 1770:20,

1770:34, 1772:37,

1776:25, 1776:26,

1776:42, 1777:4,

1798:13, 1798:14

guess [10] - 1712:23,

1712:46, 1717:40,

1723:12, 1725:1,

1725:39, 1735:42,

1752:24, 1778:33,

1801:47

guidance [2] - 1779:2,

1779:9

guide [4] - 1701:5,

1765:25, 1777:28,

1790:1

guidelines [1] -

1717:18

H

half [4] - 1705:26,

1706:15, 1764:40,

1779:20

halfway [1] - 1767:46

Hall [1] - 1696:11

hamper [1] - 1732:11

handle [1] - 1782:19

happy [1] - 1769:7

hard [14] - 1716:6,

1720:41, 1720:43,

1721:9, 1726:44,

1728:20, 1733:6,

1733:7, 1733:38,

1762:35, 1776:42,

1776:43, 1801:2

harm [1] - 1763:3

Hastings [1] - 1714:42

heading [6] - 1760:39,

1766:31, 1768:17,

1768:35, 1769:32,

1770:31

headline [1] - 1773:14

heads [1] - 1702:21

HEALTH [1] - 1696:5

Health [127] - 1698:33,

1698:35, 1698:36,

1699:6, 1699:42,

1700:33, 1704:1,

1713:20, 1713:33,

1713:36, 1714:19,

1714:34, 1715:12,

1715:24, 1715:28,

1715:29, 1716:16,

1717:19, 1717:37,

1717:46, 1718:15,

1718:22, 1718:35,

1719:19, 1719:26,

1720:3, 1720:5,

1722:2, 1722:23,

1722:24, 1725:15,

1726:34, 1726:43,

1728:23, 1729:35,

1730:46, 1731:24,

1732:21, 1732:30,

1732:39, 1733:42,

1735:29, 1735:38,

1737:2, 1737:11,

1737:17, 1737:32,

1737:33, 1737:44,

1738:7, 1738:10,

1738:15, 1738:16,

1738:20, 1741:8,

1742:36, 1742:38,

1742:40, 1742:43,

1742:44, 1742:45,

1743:6, 1743:10,

1743:11, 1743:17,

1743:25, 1743:27,

1743:38, 1743:42,

1743:45, 1744:4,

1744:7, 1744:9,

1744:11, 1744:47,

1745:4, 1747:27,

1747:43, 1750:3,

1750:18, 1750:23,

1750:24, 1750:35,

1750:36, 1750:39,

1751:1, 1751:4,

1751:32, 1752:32,

1753:3, 1753:5,

1753:11, 1753:12,

1753:19, 1753:20,

1753:22, 1753:23,

1753:24, 1753:26,

1753:38, 1753:41,

1753:45, 1755:41,

1757:2, 1758:21,

1765:35, 1765:36,

1771:10, 1771:21,

1772:36, 1775:18,

1777:10, 1777:34,

1781:2, 1781:25,

1782:3, 1786:43,

1787:13, 1789:44,

1796:32, 1801:12,

1803:37

health [477] - 1698:34,

1698:44, 1699:8,

1699:14, 1699:29,

1699:44, 1700:15,

1700:18, 1700:20,

1700:25, 1700:36,

.25/07/2019 (18)


14

1700:37, 1700:38,

1700:39, 1700:44,

1701:3, 1701:6,

1701:20, 1702:1,

1702:2, 1703:3,

1703:6, 1703:11,

1703:16, 1703:38,

1704:2, 1704:8,

1704:26, 1704:27,

1704:34, 1704:36,

1704:39, 1704:46,

1705:6, 1705:33,

1705:44, 1706:43,

1707:36, 1707:38,

1708:14, 1709:7,

1711:39, 1712:16,

1713:46, 1714:13,

1714:14, 1714:17,

1714:18, 1714:22,

1714:24, 1714:30,

1714:36, 1714:38,

1714:44, 1714:47,

1715:4, 1715:11,

1715:20, 1715:26,

1715:30, 1715:36,

1715:46, 1715:47,

1716:3, 1716:8,

1716:12, 1716:16,

1716:17, 1716:21,

1716:40, 1716:44,

1717:29, 1717:32,

1717:33, 1717:38,

1717:41, 1717:47,

1718:2, 1718:5,

1718:8, 1718:9,

1718:14, 1718:30,

1718:31, 1718:37,

1719:35, 1719:37,

1719:46, 1720:13,

1720:15, 1720:18,

1720:20, 1720:21,

1720:22, 1720:33,

1721:1, 1721:32,

1721:37, 1721:40,

1721:44, 1722:8,

1722:21, 1722:31,

1722:46, 1722:47,

1723:1, 1723:8,

1723:13, 1723:15,

1723:24, 1723:28,

1723:30, 1723:31,

1723:34, 1723:43,

1723:44, 1724:3,

1724:7, 1724:35,

1724:36, 1724:38,

1724:47, 1725:2,

1725:7, 1725:17,

1725:21, 1725:22,

1725:30, 1725:35,

1725:41, 1725:42,

1726:2, 1726:19,

1726:45, 1727:10,

1727:14, 1727:21,

1727:22, 1727:23,

1727:24, 1727:25,

1727:26, 1727:32,

1727:37, 1727:40,

1728:10, 1728:12,

1728:14, 1728:19,

1728:21, 1728:28,

1728:31, 1728:37,

1728:47, 1729:5,

1729:10, 1729:23,

1729:37, 1730:16,

1730:22, 1730:46,

1731:10, 1731:14,

1731:17, 1731:27,

1732:12, 1732:18,

1732:23, 1732:32,

1732:36, 1732:38,

1732:42, 1733:4,

1733:11, 1733:12,

1733:17, 1733:22,

1733:26, 1733:28,

1733:35, 1733:37,

1733:43, 1733:46,

1734:1, 1734:6,

1734:44, 1735:2,

1735:3, 1735:7,

1735:24, 1735:37,

1735:43, 1736:7,

1736:12, 1736:20,

1737:23, 1737:27,

1737:46, 1738:6,

1738:12, 1738:24,

1738:25, 1738:27,

1738:29, 1738:30,

1738:31, 1738:40,

1738:46, 1739:35,

1740:10, 1740:14,

1740:16, 1740:26,

1740:33, 1740:36,

1740:46, 1741:9,

1741:10, 1741:35,

1741:41, 1741:43,

1742:13, 1742:18,

1742:33, 1742:38,

1742:40, 1742:43,

1742:47, 1743:7,

1743:9, 1743:12,

1743:15, 1743:16,

1743:17, 1743:23,

1743:24, 1743:36,

1743:40, 1743:44,

1743:47, 1744:6,

1744:8, 1744:14,

1744:18, 1744:20,

1744:22, 1744:29,

1744:38, 1744:45,

1745:1, 1745:3,

1745:12, 1745:21,

1745:22, 1745:25,

1745:27, 1745:31,

1745:35, 1746:1,

1746:23, 1746:24,

1746:31, 1746:35,

1746:42, 1747:4,

1747:6, 1747:9,

1747:11, 1747:15,

1747:21, 1747:25,

1747:26, 1747:29,

1747:30, 1747:33,

1747:39, 1747:46,

1748:3, 1748:4,

1748:10, 1748:14,

1748:15, 1748:17,

1748:20, 1748:27,

1748:30, 1748:42,

1748:46, 1749:1,

1749:4, 1749:13,

1749:21, 1749:23,

1749:28, 1749:35,

1749:44, 1750:4,

1750:6, 1750:9,

1750:19, 1750:35,

1750:45, 1751:5,

1751:16, 1751:19,

1751:41, 1751:43,

1751:46, 1752:1,

1752:2, 1752:9,

1752:12, 1752:15,

1752:30, 1752:42,

1753:2, 1753:5,

1753:10, 1753:13,

1753:17, 1753:31,

1753:38, 1753:47,

1754:2, 1754:4,

1754:7, 1754:24,

1754:27, 1754:29,

1754:32, 1754:37,

1754:39, 1755:14,

1756:30, 1756:38,

1757:21, 1757:32,

1758:5, 1758:8,

1758:14, 1759:46,

1760:3, 1762:45,

1763:1, 1764:11,

1764:29, 1765:11,

1765:37, 1766:15,

1766:16, 1766:18,

1766:20, 1766:36,

1767:9, 1767:21,

1768:5, 1768:35,

1768:38, 1768:39,

1768:41, 1768:47,

1769:2, 1769:36,

1770:5, 1770:7,

1770:35, 1771:19,

1771:30, 1772:6,

1772:39, 1774:23,

1774:24, 1775:18,

1777:31, 1777:32,

1777:46, 1778:10,

1785:1, 1785:32,

1786:37, 1787:19,

1787:23, 1787:24,

1787:28, 1787:29,

1787:30, 1787:38,

1787:46, 1788:9,

1789:25, 1789:28,

1789:30, 1789:31,

1789:33, 1789:34,

1789:39, 1790:2,

1790:3, 1790:47,

1791:7, 1791:31,

1791:40, 1792:8,

1792:9, 1792:19,

1792:22, 1792:25,

1792:29, 1792:34,

1792:35, 1793:3,

1793:7, 1793:9,

1793:14, 1793:17,

1794:17, 1794:21,

1794:26, 1794:37,

1794:44, 1795:3,

1795:6, 1795:8,

1795:21, 1795:29,

1795:40, 1796:17,

1796:25, 1796:27,

1796:44, 1796:47,

1797:4, 1797:5,

1797:10, 1797:11,

1797:15, 1797:24,

1797:44, 1798:6,

1798:14, 1798:15,

1798:24, 1798:28,

1798:29, 1798:30,

1798:32, 1799:1,

1801:3, 1801:37,

1802:7, 1802:26,

1802:28, 1802:30,

1802:31, 1802:40,

1802:45, 1802:47,

1803:15, 1803:22,

1803:31, 1803:45

Health's [3] - 1719:26,

1724:6, 1742:46

health-driven [1] -

1762:45

health-related [1] -

1770:35

health-specific [1] -

1792:19

hear [2] - 1702:38,

1716:39

heard [12] - 1759:39,

1762:31, 1764:40,

1773:17, 1776:24,

1784:20, 1785:39,

1792:4, 1794:14,

1801:32, 1801:39,

1801:41

hearing [3] - 1793:7,

1795:17, 1796:13

heart [1] - 1798:44

heavy [1] - 1716:9

held [1] - 1755:44

help [10] - 1709:25,

1722:17, 1733:18,

1756:24, 1762:47,

1768:24, 1770:4,

1770:9, 1791:38,

1800:5

helped [1] - 1799:3

helpful [7] - 1721:39,

1730:5, 1733:16,

1735:33, 1735:37,

1749:7, 1785:47

helps [1] - 1721:36

hence [2] - 1742:28,

1742:31

herself [1] - 1741:7

high [8] - 1715:2,

1741:43, 1741:46,

1747:13, 1758:14,

1762:37, 1763:4,

1772:16

higher [3] - 1700:3,

1727:11, 1769:42

Higher [1] - 1756:6

highest [3] - 1752:37,

1776:25, 1776:26

highlighted [1] -

1712:19

highly [1] - 1739:23

Highway [1] - 1752:39

himself [1] - 1740:41

historical [6] -

1699:46, 1751:9,

1764:3, 1772:19,

1783:42, 1796:4

historically [4] -

1704:20, 1747:5,

1751:16, 1783:28

history [1] - 1773:20

hit [2] - 1725:15,

1800:37

hold [4] - 1697:15,

1703:16, 1764:4,

1773:23

holding [1] - 1755:47

home [4] - 1703:45,

1710:42, 1730:21,

1741:7

homeless [1] -

1739:31

homelessness [2] -

1739:23, 1739:28

hopefully [2] -

1741:45, 1765:46

hospital [16] -

1703:20, 1741:21,

1743:41, 1746:23,

.25/07/2019 (18)


15

1749:14, 1749:16,

1749:32, 1750:9,

1750:10, 1752:33,

1752:35, 1757:34,

1787:45, 1790:41,

1801:40

Hospital [4] - 1719:19,

1731:26, 1737:18,

1751:24

hospital-based [1] -

1801:40

hospitals [10] -

1702:11, 1723:37,

1739:2, 1739:5,

1739:12, 1739:13,

1744:46, 1754:1,

1791:13, 1795:2

hour [3] - 1794:19,

1794:24, 1794:36

hours [5] - 1734:21,

1747:37, 1794:16,

1794:17, 1794:29

house [1] - 1727:7

housing [2] - 1757:41,

1770:26

Housing [1] - 1738:1

Hub [1] - 1731:5

huddle [1] - 1716:30

huddles [1] - 1716:24

huge [2] - 1715:36,

1729:22

human [3] - 1703:3,

1704:26, 1802:45

Human [7] - 1699:6,

1717:46, 1722:24,

1755:41, 1772:36,

1786:43, 1787:13

Hume [1] - 1752:39

hygiene [1] - 1730:18

hypothetical [1] -

1708:11

I

i.e [1] - 1753:34

idea [5] - 1707:31,

1708:37, 1714:35,

1718:26, 1725:39

ideas [3] - 1707:32,

1730:3, 1751:15

identification [1] -

1789:1

identified [15] -

1699:18, 1701:29,

1703:5, 1715:25,

1740:27, 1740:35,

1745:18, 1748:6,

1757:3, 1759:32,

1761:43, 1762:11,

1762:20, 1773:31,

1778:17

identifies [1] -

1773:30

identify [8] - 1701:21,

1745:37, 1747:29,

1748:38, 1749:3,

1767:32, 1773:29,

1801:2

identifying [3] -

1710:30, 1716:27,

1761:38

ill [3] - 1749:31,

1749:45, 1759:46

ill-health [1] - 1759:46

illness [19] - 1700:15,

1738:41, 1739:32,

1739:44, 1740:4,

1740:41, 1740:44,

1746:18, 1757:45,

1758:18, 1758:42,

1758:47, 1759:35,

1761:13, 1766:19,

1766:20, 1770:6,

1789:40, 1798:40

illnesses [1] - 1798:41

illustrative [1] -

1736:19

imbalance [3] -

1699:7, 1699:22,

1772:5

imbalances [1] -

1770:37

immediately [1] -

1795:23

imminent [1] - 1765:5

immunity [4] -

1764:14, 1764:21,

1787:7, 1797:47

Impact [1] - 1782:39

impact [7] - 1707:22,

1712:35, 1724:7,

1761:22, 1771:22,

1781:16, 1783:41

impacted [1] -

1787:31

impacts [4] - 1703:43,

1764:41, 1768:21,

1769:3

impediment [1] -

1784:46

impediments [5] -

1719:41, 1772:17,

1772:20, 1774:17,

1785:5

impetus [1] - 1739:34

implement [7] -

1740:20, 1740:28,

1769:6, 1769:19,

1784:47, 1786:20,

1799:17

implementation [9] -

1710:28, 1732:11,

1740:32, 1751:35,

1783:12, 1783:30,

1783:32, 1785:20,

1802:15

Implementation [1] -

1782:35

implemented [6] -

1712:34, 1740:9,

1786:2, 1793:38,

1799:31, 1799:39

implementing [1] -

1712:2

implication [1] -

1744:30

implications [1] -

1774:26

implicit [2] - 1772:10,

1774:14

importance [5] -

1747:12, 1748:30,

1771:3, 1786:9,

1791:30

important [41] -

1697:41, 1699:36,

1709:35, 1710:12,

1711:16, 1712:46,

1718:18, 1733:14,

1760:30, 1763:21,

1767:3, 1770:39,

1770:43, 1775:16,

1777:11, 1777:27,

1777:39, 1777:42,

1779:41, 1780:2,

1780:22, 1781:2,

1781:9, 1783:38,

1784:6, 1785:18,

1785:46, 1787:29,

1789:11, 1789:15,

1790:5, 1795:24,

1797:9, 1798:3,

1799:5, 1800:38,

1802:12, 1802:41,

1803:20, 1803:26

importantly [2] -

1702:28, 1710:8

impossible [1] -

1725:13

improve [9] - 1740:40,

1747:47, 1756:36,

1760:17, 1760:30,

1761:18, 1770:39,

1787:30, 1791:24

improved [5] -

1699:38, 1708:14,

1760:30, 1781:26,

1781:32

improvement [11] -

1701:15, 1707:20,

1718:9, 1741:19,

1741:35, 1754:44,

1762:24, 1769:15,

1788:13, 1788:16,

1788:26

improvements [8] -

1711:25, 1712:18,

1732:12, 1742:15,

1751:39, 1752:1,

1776:19, 1780:6

improving [2] -

1760:42, 1802:47

inadequate [3] -

1791:11, 1791:14,

1791:18

inadvertently [2] -

1780:12, 1780:23

inappropriate [1] -

1796:9

incentive [1] - 1780:12

incentives [2] -

1762:7, 1773:18

incident [2] - 1735:26,

1753:36

incidents [7] - 1722:5,

1735:6, 1748:16,

1749:2, 1753:37,

1753:39, 1753:42

inclined [1] - 1704:28

include [7] - 1697:19,

1709:37, 1717:41,

1728:17, 1729:28,

1792:25, 1794:2

included [5] -

1731:27, 1739:11,

1792:19, 1793:3,

1801:18

includes [1] - 1766:40

including [18] -

1700:8, 1708:24,

1709:18, 1712:5,

1717:37, 1728:41,

1756:1, 1762:21,

1767:8, 1768:5,

1769:43, 1770:9,

1777:31, 1783:22,

1794:21, 1797:24,

1799:43, 1803:6

Inclusion [1] - 1756:2

inclusion [2] -

1700:13, 1718:7

incorporate [1] -

1750:19

incorporated [1] -

1751:2

incorporating [1] -

1787:18

increase [5] - 1746:40,

1792:46, 1797:44,

1797:45, 1798:1

increased [1] -

1758:19

increases [3] -

1746:32, 1746:35,

1758:27

increasing [3] -

1699:26, 1757:23,

1787:17

increasingly [1] -

1797:22

incredibly [6] -

1725:28, 1727:1,

1757:7, 1760:29,

1767:2, 1781:2

incumbent [1] -

1709:27

indeed [1] - 1705:32

independent [5] -

1697:36, 1698:6,

1698:19, 1698:21,

1800:5

Independent [3] -

1737:18, 1751:24,

1796:32

index [2] - 1707:1,

1707:2

indexed [2] - 1746:32,

1746:33

indicate [1] - 1778:33

indicated [2] - 1775:2,

1795:32

indications [1] -

1735:15

indicator [2] - 1705:9,

1705:21

indicators [29] -

1705:12, 1705:13,

1705:16, 1705:17,

1705:26, 1705:28,

1705:35, 1706:34,

1721:22, 1722:18,

1730:12, 1731:21,

1735:4, 1736:7,

1744:15, 1744:18,

1744:37, 1747:28,

1747:34, 1747:35,

1747:36, 1747:39,

1768:42, 1769:13,

1769:14, 1769:26,

1775:45, 1781:46,

1794:4

indirect [1] - 1767:5

individual [5] -

1704:8, 1709:12,

1732:28, 1774:24,

1791:40

individually [1] -

1732:14

individuals [1] -

.25/07/2019 (18)


16

1758:31

inefficient [1] -

1731:46

inequities [1] -

1699:46

inequity [1] - 1701:16

infections [1] - 1735:5

infectious [1] -

1797:20

inflexible [1] - 1796:3

influence [3] -

1721:31, 1760:15,

1767:5

influenced [2] -

1764:32, 1786:18

inform [1] - 1761:45

Information [1] -

1775:19

information [49] -

1697:43, 1703:40,

1703:41, 1703:42,

1703:47, 1710:24,

1716:30, 1719:44,

1719:45, 1719:46,

1721:35, 1722:5,

1722:31, 1722:36,

1722:38, 1722:42,

1737:47, 1738:2,

1743:36, 1744:1,

1744:14, 1744:21,

1744:28, 1744:34,

1744:35, 1747:20,

1747:26, 1747:27,

1747:45, 1748:33,

1748:37, 1755:17,

1760:14, 1764:16,

1765:32, 1765:34,

1765:38, 1765:39,

1768:2, 1769:46,

1773:25, 1773:37,

1774:20, 1781:3,

1782:18, 1788:20,

1791:41, 1797:46

informed [6] -

1699:18, 1702:30,

1705:36, 1712:42,

1770:18, 1771:4

informing [1] -

1778:25

InfoXchange [1] -

1737:18

Infrastructure [1] -

1760:6

infrastructure [31] -

1699:34, 1699:37,

1700:28, 1703:13,

1703:14, 1712:29,

1712:33, 1721:25,

1726:36, 1726:41,

1728:8, 1729:26,

1729:28, 1734:17,

1734:24, 1734:34,

1761:36, 1765:23,

1775:37, 1776:31,

1777:31, 1778:22,

1785:24, 1785:26,

1785:31, 1786:34,

1786:37, 1787:35,

1787:39, 1798:31,

1802:3

ingredient [1] -

1800:38

inhibit [2] - 1788:12,

1788:16

inhibited [4] -

1775:37, 1775:41,

1776:5, 1776:8

inhibiting [1] -

1709:42

inhibits [1] - 1701:15

initial [1] - 1778:37

initiative [1] - 1722:23

initiatives [1] -

1803:41

injuries [2] - 1716:28,

1739:43

innovation [6] -

1783:29, 1783:32,

1783:37, 1783:40,

1784:6, 1784:7

innovations [2] -

1742:15, 1770:35

inpatient [16] - 1715:2,

1715:3, 1742:20,

1752:43, 1753:34,

1754:40, 1757:25,

1757:28, 1757:37,

1757:39, 1785:41,

1785:42, 1786:10,

1786:24, 1794:46,

1795:42

input [3] - 1700:19,

1747:36, 1789:12

input-based [1] -

1700:19

insight [1] - 1781:31

insights [1] - 1790:8

instability [1] -

1783:27

Institute [2] - 1737:8,

1756:20

institution [3] -

1739:3, 1800:13,

1800:37

institutional [3] -

1763:24, 1799:42,

1801:26

institutionalisation

[4] - 1738:31,

1738:36, 1738:47,

1786:2

institutions [4] -

1738:42, 1739:20,

1740:35, 1763:37

insufficient [4] -

1730:45, 1732:17,

1733:25, 1759:7

integrated [5] -

1707:11, 1733:42,

1763:5, 1789:33,

1801:20

integrating [3] -

1715:44, 1762:42,

1787:23

integration [3] -

1709:43, 1732:17,

1733:26

intended [3] -

1700:29, 1756:39,

1784:12

intending [1] -

1780:42

intense [1] - 1768:27

intensive [3] -

1713:43, 1758:40,

1759:8

intent [7] - 1698:16,

1698:19, 1738:44,

1778:20, 1778:35,

1778:36, 1781:3

intention [1] - 1802:29

intentional [1] -

1774:14

inter [1] - 1799:32

inter-dependencies

[1] - 1799:32

interaction [1] -

1707:7

interactions [1] -

1727:45

interdependency [1] -

1752:8

interest [7] - 1734:42,

1739:30, 1748:39,

1764:14, 1764:21,

1787:6, 1797:46

interested [5] -

1705:19, 1705:22,

1748:17, 1799:18,

1802:1

interesting [1] -

1798:22

interestingly [1] -

1714:16

interests [2] - 1783:8,

1803:35

interface [3] -

1789:43, 1803:15,

1803:19

interfaces [1] -

1803:22

intermediate [11] -

1707:31, 1707:32,

1707:37, 1707:41,

1707:44, 1708:1,

1708:10, 1708:12,

1708:20, 1708:33

internal [10] - 1697:26,

1748:11, 1765:47,

1766:30, 1767:17,

1767:45, 1768:16,

1768:34, 1769:30,

1770:30

internal/external [1] -

1722:6

internally [2] -

1733:27, 1781:4

interrelated [1] -

1752:3

interrogate [1] -

1774:13

intersections [1] -

1770:25

intervention [2] -

1740:1, 1789:40

interventions [2] -

1759:12, 1780:5

INTO [1] - 1696:5

intra [1] - 1763:8

introduced [2] -

1767:39, 1779:13

introduction [1] -

1700:24

invested [1] - 1768:25

investigating [1] -

1795:29

investigation [1] -

1786:5

investing [2] -

1733:22, 1770:44

investment [13] -

1699:12, 1729:31,

1731:12, 1731:18,

1761:38, 1765:26,

1772:32, 1772:46,

1772:47, 1774:4,

1777:28, 1786:24,

1786:31

investments [2] -

1776:33, 1798:7

involuntary [1] -

1771:34

involve [2] - 1745:43,

1780:32

involved [10] - 1712:6,

1733:34, 1760:28,

1761:14, 1763:35,

1763:38, 1780:34,

1781:22, 1796:41,

1802:2

involves [4] - 1745:30,

1761:36, 1761:41,

1762:2

involving [1] -

1781:21

irrelevant [1] -

1711:21

ISR [1] - 1735:26

issue [24] - 1699:19,

1701:38, 1702:45,

1705:7, 1710:26,

1714:37, 1726:19,

1726:36, 1734:25,

1735:2, 1772:21,

1778:31, 1782:45,

1783:16, 1785:3,

1785:26, 1788:22,

1790:14, 1791:13,

1791:20, 1800:42,

1803:29, 1803:30

issues [49] - 1701:10,

1701:25, 1701:26,

1702:6, 1702:7,

1705:33, 1711:15,

1712:19, 1715:26,

1715:27, 1715:38,

1716:27, 1716:28,

1716:39, 1716:42,

1728:8, 1732:2,

1734:39, 1738:11,

1738:13, 1740:34,

1741:24, 1743:35,

1748:18, 1748:42,

1748:47, 1749:1,

1750:27, 1752:42,

1753:42, 1760:43,

1778:18, 1778:19,

1778:39, 1778:46,

1779:10, 1780:21,

1782:9, 1784:26,

1784:27, 1784:39,

1791:22, 1791:39,

1792:27, 1802:31,

1803:19, 1803:39

IT [5] - 1754:32,

1774:37, 1774:43,

1782:39, 1782:45

iteration [1] - 1765:4

itself [4] - 1698:26,

1748:27, 1760:22,

1778:30

J

Jacinda [1] - 1708:35

Jennifer [2] - 1736:30,

1736:39

JENNIFER [1] -

1736:42

Jobs [1] - 1756:11

.25/07/2019 (18)


17

join [2] - 1704:10,

1763:28

joined [1] - 1763:4

joint [3] - 1785:6,

1791:42, 1791:44

jointly [1] - 1753:40

journey [4] - 1775:9,

1775:12, 1791:47,

1797:40

judged [1] - 1741:8

JULY [1] - 1804:15

July [2] - 1696:18,

1737:12

JUNE [1] - 1736:42

June [1] - 1698:36

jurisdiction [1] -

1740:18

jurisdictions [2] -

1751:26, 1751:28

justice [3] - 1758:1,

1770:26, 1803:6

K

keen [1] - 1718:23

keep [3] - 1763:10,

1800:16, 1800:31

kept [2] - 1742:27,

1794:30

key [13] - 1701:2,

1706:27, 1708:32,

1711:26, 1718:20,

1732:10, 1738:36,

1740:33, 1769:13,

1770:31, 1785:44,

1797:40, 1801:2

kilometres [1] -

1714:40

kind [22] - 1701:27,

1705:15, 1714:39,

1716:6, 1720:21,

1724:11, 1728:22,

1729:14, 1730:19,

1732:35, 1732:37,

1733:33, 1733:34,

1733:37, 1734:27,

1769:5, 1774:38,

1788:37, 1790:19,

1795:5, 1800:29,

1800:32

kinds [1] - 1722:30

knowing [1] - 1703:16

knowledge [4] -

1720:12, 1733:36,

1733:47, 1788:34

knows [1] - 1721:36

KPI [2] - 1723:43,

1793:31

KPIs [21] - 1704:34,

1704:42, 1704:43,

1704:46, 1705:1,

1721:43, 1722:4,

1723:34, 1723:42,

1728:7, 1729:37,

1729:38, 1748:6,

1748:7, 1792:19,

1792:21, 1792:23,

1792:34, 1792:35,

1792:46, 1794:6

Kym [1] - 1755:35

KYM [1] - 1755:38

L

labour [1] - 1746:32

lack [23] - 1699:11,

1699:19, 1700:8,

1701:13, 1721:34,

1726:41, 1732:3,

1732:16, 1732:19,

1732:44, 1733:34,

1733:35, 1733:36,

1735:32, 1757:23,

1757:40, 1770:11,

1774:47, 1782:22,

1798:23, 1798:25,

1798:36

lagged [1] - 1742:31

lagging [1] - 1789:29

Lakeside [1] - 1738:42

land [1] - 1733:29

language [2] - 1733:5,

1785:17

Langwarrin [1] -

1714:41

lapsed [1] - 1742:32

large [7] - 1714:23,

1721:47, 1722:10,

1729:4, 1741:20,

1743:42, 1747:33

largely [1] - 1734:44

larger [3] - 1728:43,

1745:15, 1745:16

last [18] - 1708:35,

1714:10, 1715:19,

1727:19, 1727:36,

1728:13, 1731:2,

1731:4, 1731:9,

1731:25, 1736:1,

1764:40, 1775:16,

1776:33, 1782:36,

1783:36, 1786:42,

1788:29

late [2] - 1715:19,

1725:12

launched [1] - 1741:4

laws [1] - 1698:2

layers [1] - 1784:36

lead [8] - 1776:31,

1779:7, 1780:12,

1786:33, 1802:1,

1802:8, 1802:11

Lead [1] - 1756:10

leader [5] - 1715:21,

1775:31, 1778:44,

1779:38, 1793:13

leader's [1] - 1763:42

leadership [21] -

1703:37, 1714:3,

1714:9, 1714:21,

1715:27, 1741:25,

1741:34, 1742:32,

1762:38, 1763:15,

1772:44, 1786:19,

1790:36, 1790:39,

1791:1, 1791:22,

1791:25, 1796:28,

1798:5, 1800:21,

1800:26

Leadership [2] -

1713:40, 1722:29

leading [7] - 1715:31,

1716:7, 1752:15,

1761:42, 1787:45,

1801:7, 1803:18

leap [1] - 1766:43

leaping [1] - 1780:8

learning [2] - 1773:47,

1774:8

learnings [1] -

1801:21

least [5] - 1750:26,

1776:23, 1791:11,

1795:2, 1800:35

leave [1] - 1776:22

leaves [2] - 1701:9,

1789:16

leaving [1] - 1792:32

led [9] - 1722:23,

1757:6, 1776:28,

1785:45, 1790:40,

1791:4, 1796:13,

1797:47, 1802:35

LEE [1] - 1755:38

LEE-ANNE [1] -

1755:38

left [1] - 1749:17

legislative [2] -

1698:25, 1750:13

length [3] - 1744:8,

1774:22, 1775:26

lengths [1] - 1757:36

lens [1] - 1764:3

less [9] - 1704:28,

1707:34, 1726:46,

1746:11, 1755:7,

1758:17, 1780:13,

1795:11

level [57] - 1697:47,

1699:12, 1701:10,

1709:12, 1709:42,

1719:22, 1720:7,

1721:9, 1721:32,

1721:39, 1722:33,

1732:5, 1732:6,

1732:31, 1735:33,

1737:42, 1741:34,

1745:32, 1746:3,

1746:16, 1752:11,

1762:12, 1762:37,

1763:4, 1763:16,

1763:23, 1763:24,

1763:30, 1765:30,

1765:31, 1767:39,

1769:1, 1771:41,

1772:16, 1772:21,

1773:23, 1778:10,

1782:23, 1782:28,

1788:3, 1788:11,

1789:2, 1789:16,

1789:22, 1791:39,

1795:34, 1798:17,

1799:43, 1800:2,

1800:10, 1800:14,

1800:17, 1800:19,

1801:7, 1801:17,

1801:27, 1801:44

levels [6] - 1697:27,

1722:1, 1747:13,

1752:11, 1763:20,

1771:35

leverage [3] - 1788:33,

1789:35, 1804:2

leveraged [1] -

1787:36

leveraging [1] -

1803:35

levers [1] - 1767:4

lie [1] - 1702:46

life [1] - 1714:40

lift [1] - 1802:17

lifted [1] - 1775:23

light [3] - 1775:27,

1775:28, 1778:7

likelihood [1] -

1758:27

likely [6] - 1741:36,

1741:38, 1758:42,

1759:14, 1769:42,

1770:4

limitations [7] -

1709:35, 1711:1,

1712:29, 1773:31,

1773:36, 1785:27,

1785:30

limited [6] - 1714:18,

1723:43, 1731:16,

1735:43, 1744:34,

1797:37

limits [2] - 1745:38,

1764:36

line [7] - 1725:16,

1749:38, 1749:41,

1764:22, 1768:6,

1768:38, 1793:45

link [6] - 1708:20,

1761:18, 1773:23,

1778:47, 1793:32,

1803:3

linkage [1] - 1709:26

linked [3] - 1708:23,

1803:4, 1803:7

linking [2] - 1802:45,

1803:1

links [1] - 1709:18

Lisa [1] - 1696:34

list [1] - 1735:40

listening [1] - 1715:39

lists [1] - 1723:39

lives [2] - 1760:42,

1770:40

load [1] - 1726:9

local [12] - 1697:27,

1745:43, 1746:9,

1746:11, 1746:12,

1746:16, 1765:33,

1765:37, 1767:3,

1773:24, 1789:17

locality [1] - 1770:12

long-stay [1] -

1757:38

long-term [2] -

1708:18, 1775:37

longer-term [1] -

1759:13

longevity [1] -

1783:46

longstanding [2] -

1701:44, 1702:20

look [27] - 1710:26,

1716:5, 1722:33,

1722:43, 1723:36,

1726:47, 1730:9,

1747:1, 1747:46,

1755:17, 1759:27,

1761:17, 1767:22,

1768:10, 1768:16,

1769:14, 1772:35,

1777:6, 1777:47,

1791:38, 1792:27,

1796:32, 1796:38,

1797:25, 1798:12,

1799:27, 1803:11

looked [2] - 1705:1,

1730:39

looking [21] - 1701:40,

1705:43, 1716:26,

1723:9, 1727:6,

.25/07/2019 (18)


18

1747:38, 1748:46,

1748:47, 1766:16,

1769:6, 1774:27,

1777:14, 1778:24,

1783:43, 1783:45,

1794:7, 1795:40,

1795:42, 1796:29,

1800:43

looks [3] - 1744:17,

1777:45, 1795:34

loops [1] - 1761:24

lose [2] - 1783:24

lost [1] - 1716:27

low [1] - 1700:8

lowest [3] - 1752:13,

1776:28, 1785:41

lunch [1] - 1736:29

LUNCH [1] - 1736:37

LUNCHEON [1] -

1736:35

M

m'mm [1] - 1729:39

machine [2] -

1773:47, 1774:8

main [1] - 1729:8

mainstream [1] -

1739:5

mainstreamed [1] -

1739:2

mainstreaming [3] -

1738:30, 1792:5,

1798:47

maintaining [1] -

1768:26

maintains [1] -

1799:28

major [3] - 1699:11,

1705:7, 1705:10

majority [1] - 1731:8

makeshift [1] -

1731:39

manage [12] -

1702:39, 1703:21,

1703:22, 1703:25,

1710:7, 1726:9,

1726:13, 1730:18,

1731:45, 1734:2,

1787:43, 1793:9

managed [5] -

1727:23, 1729:14,

1753:40, 1792:43,

1799:32

management [23] -

1714:3, 1719:37,

1719:44, 1734:43,

1735:44, 1743:10,

1743:37, 1744:37,

1745:13, 1748:36,

1748:40, 1774:42,

1782:8, 1782:12,

1782:28, 1782:46,

1783:12, 1784:37,

1787:37, 1792:11,

1793:33, 1793:39,

1794:10

manager [3] -

1765:20, 1766:47,

1779:43

managers [1] -

1702:39

managing [1] - 1776:9

March [3] - 1698:35,

1715:11, 1724:12

Marie [1] - 1741:4

MARK [1] - 1697:5

market [1] - 1774:37

mass [1] - 1733:29

Master [2] - 1713:36,

1737:7

master [1] - 1731:19

match [5] - 1721:19,

1724:29, 1724:31,

1724:39, 1724:41

matter [6] - 1703:12,

1703:28, 1712:46,

1754:22, 1787:6,

1795:10

matters [5] - 1698:12,

1706:4, 1734:8,

1764:15, 1800:22

matters" [1] - 1765:11

maturation [1] -

1790:24

maturing [1] - 1792:8

McSherry [1] -

1696:29

mean [17] - 1704:42,

1704:43, 1704:45,

1710:45, 1726:14,

1726:33, 1731:32,

1735:10, 1746:11,

1754:13, 1781:14,

1783:16, 1784:35,

1791:28, 1792:38,

1793:22, 1799:8

meaning [2] -

1753:22, 1762:18

meaningful [1] -

1723:5

means [9] - 1762:17,

1766:15, 1766:19,

1780:2, 1780:37,

1795:34, 1796:22,

1801:43, 1803:2

meant [1] - 1740:4

meantime [1] -

1776:34

measurable [2] -

1707:47, 1709:40

measure [12] -

1701:35, 1705:27,

1706:8, 1706:46,

1707:26, 1710:11,

1729:41, 1729:45,

1733:20, 1794:30,

1796:23

measured [2] -

1705:30, 1729:34

measurement [5] -

1701:34, 1704:32,

1706:25, 1707:29,

1783:38

measures [33] -

1699:24, 1705:34,

1705:46, 1707:1,

1710:8, 1721:21,

1721:35, 1722:17,

1722:44, 1722:45,

1723:5, 1723:8,

1730:12, 1730:21,

1733:20, 1733:21,

1735:27, 1736:17,

1739:41, 1747:36,

1761:21, 1769:25,

1771:33, 1779:31,

1781:1, 1781:25,

1781:32, 1781:35,

1781:39, 1781:43,

1782:13, 1785:14,

1794:2

measuring [4] -

1732:33, 1780:3,

1780:38, 1780:47

mechanism [2] -

1801:12, 1801:13

Mechanisms [1] -

1760:5

mechanisms [8] -

1760:22, 1762:13,

1763:27, 1773:15,

1791:43, 1792:7,

1796:1, 1801:8

media [1] - 1739:29

medical [3] - 1753:28,

1754:26, 1754:31

Medical [2] - 1737:19,

1737:20

medically [1] - 1753:8

medicine [1] -

1745:26

meet [15] - 1699:29,

1700:5, 1701:4,

1716:31, 1728:2,

1729:9, 1729:42,

1730:47, 1760:16,

1761:43, 1762:5,

1762:20, 1764:1,

1793:31, 1794:3

meeting [9] - 1716:25,

1719:15, 1727:19,

1727:37, 1757:4,

1765:5, 1792:28,

1793:26

meetings [4] -

1716:35, 1727:39,

1728:13, 1728:14

meets [1] - 1728:45

Melbourne [28] -

1696:11, 1696:13,

1719:19, 1719:27,

1732:40, 1742:37,

1742:42, 1742:46,

1743:9, 1743:17,

1743:25, 1743:27,

1744:4, 1744:7,

1750:23, 1750:35,

1750:39, 1750:40,

1753:5, 1753:11,

1753:19, 1753:21,

1753:22, 1753:23,

1753:41

Melbourne's [1] -

1757:17

member [6] - 1721:38,

1733:8, 1737:23,

1738:7, 1738:16,

1753:34

Members [3] -

1745:43, 1745:44,

1746:12

members [4] -

1726:13, 1733:6,

1733:7, 1788:18

memory [1] - 1718:3

Mental [24] - 1698:33,

1698:34, 1698:36,

1699:42, 1700:33,

1704:1, 1715:28,

1725:15, 1726:43,

1737:44, 1747:27,

1751:1, 1751:31,

1757:1, 1758:21,

1765:35, 1771:10,

1771:21, 1777:10,

1777:34, 1781:2,

1781:25, 1782:3,

1803:37

MENTAL [1] - 1696:5

mental [371] - 1698:34,

1698:44, 1699:8,

1699:14, 1699:29,

1699:44, 1700:15,

1700:18, 1700:20,

1700:25, 1700:36,

1700:37, 1700:38,

1700:39, 1700:44,

1701:3, 1701:7,

1701:20, 1703:38,

1704:26, 1704:34,

1704:36, 1704:38,

1704:45, 1705:6,

1705:33, 1705:44,

1706:43, 1707:36,

1707:38, 1708:14,

1709:7, 1711:38,

1712:16, 1714:13,

1714:17, 1714:22,

1714:23, 1714:44,

1714:47, 1715:4,

1715:11, 1715:20,

1715:26, 1715:30,

1715:36, 1715:46,

1715:47, 1716:3,

1716:8, 1716:12,

1716:16, 1716:21,

1716:40, 1716:44,

1717:29, 1717:32,

1717:33, 1717:38,

1717:41, 1717:47,

1718:1, 1718:5,

1718:8, 1718:9,

1718:14, 1718:31,

1718:37, 1719:37,

1720:13, 1720:15,

1720:18, 1720:20,

1720:33, 1720:47,

1721:32, 1721:37,

1721:40, 1721:44,

1722:8, 1722:31,

1723:1, 1723:8,

1723:13, 1723:24,

1723:30, 1723:31,

1723:43, 1723:44,

1724:2, 1724:7,

1724:35, 1724:36,

1724:38, 1724:47,

1725:2, 1725:7,

1725:20, 1725:30,

1725:34, 1725:41,

1725:42, 1726:45,

1727:14, 1727:21,

1727:22, 1727:23,

1727:25, 1727:26,

1727:32, 1727:37,

1727:40, 1728:10,

1728:12, 1728:13,

1728:19, 1728:21,

1728:28, 1728:31,

1728:46, 1729:10,

1729:23, 1729:37,

1730:22, 1730:46,

1731:10, 1731:14,

1731:26, 1732:12,

1732:18, 1732:23,

1732:32, 1732:42,

1733:4, 1733:12,

1733:17, 1733:22,

1733:26, 1733:28,

.25/07/2019 (18)


19

1733:35, 1733:37,

1733:43, 1733:45,

1734:1, 1734:6,

1735:3, 1735:24,

1735:37, 1735:43,

1736:20, 1737:22,

1738:6, 1738:24,

1738:25, 1738:26,

1738:30, 1738:31,

1738:39, 1738:41,

1738:46, 1739:32,

1739:35, 1739:43,

1740:3, 1740:10,

1740:14, 1740:16,

1740:26, 1740:33,

1740:36, 1740:40,

1740:44, 1740:46,

1741:10, 1741:34,

1741:43, 1742:13,

1742:18, 1742:33,

1742:38, 1742:40,

1742:43, 1742:47,

1743:6, 1743:11,

1743:15, 1743:16,

1743:23, 1743:24,

1743:36, 1743:40,

1743:43, 1743:46,

1744:6, 1744:8,

1744:14, 1744:18,

1744:20, 1744:22,

1744:38, 1744:45,

1745:1, 1745:12,

1745:20, 1745:26,

1746:1, 1746:17,

1746:24, 1746:31,

1747:4, 1747:6,

1747:9, 1747:11,

1747:15, 1747:21,

1747:33, 1748:3,

1748:4, 1748:10,

1748:13, 1748:15,

1748:17, 1748:30,

1748:42, 1749:1,

1749:13, 1749:21,

1749:35, 1750:4,

1750:6, 1750:9,

1750:19, 1750:35,

1750:45, 1751:5,

1751:16, 1751:18,

1751:41, 1751:43,

1751:46, 1751:47,

1752:2, 1752:9,

1752:12, 1752:15,

1752:42, 1753:2,

1753:5, 1753:10,

1753:13, 1753:17,

1753:31, 1753:38,

1753:47, 1754:2,

1754:4, 1754:7,

1754:24, 1754:27,

1754:29, 1754:32,

1754:37, 1754:39,

1755:14, 1756:30,

1756:38, 1757:21,

1757:32, 1757:45,

1758:5, 1758:8,

1758:14, 1759:35,

1759:45, 1760:3,

1761:13, 1763:1,

1764:11, 1764:29,

1765:10, 1766:15,

1766:16, 1766:18,

1766:19, 1766:20,

1766:35, 1767:9,

1767:21, 1768:4,

1768:35, 1768:39,

1768:41, 1768:47,

1769:2, 1769:36,

1770:4, 1770:6,

1770:7, 1770:35,

1771:19, 1771:30,

1772:6, 1772:39,

1776:27, 1777:32,

1777:46, 1778:10,

1785:1, 1785:32,

1786:37, 1787:18,

1787:23, 1787:28,

1787:30, 1787:37,

1787:38, 1787:46,

1788:9, 1789:28,

1789:30, 1789:33,

1789:39, 1790:3,

1790:47, 1792:9,

1792:18, 1792:22,

1792:25, 1792:28,

1792:34, 1792:35,

1793:3, 1793:14,

1794:17, 1794:21,

1794:26, 1794:37,

1794:43, 1795:3,

1795:8, 1795:21,

1795:29, 1795:40,

1796:24, 1796:47,

1797:4, 1797:11,

1797:24, 1797:44,

1798:6, 1798:14,

1798:15, 1798:24,

1798:28, 1798:29,

1798:30, 1798:40,

1799:1, 1801:3,

1801:37, 1802:7,

1802:26, 1802:30,

1802:31, 1802:40,

1803:14, 1803:21,

1803:31

mentally [2] - 1749:31,

1749:45

mention [5] - 1721:42,

1731:13, 1747:4,

1792:15, 1800:4

mentioned [21] -

1702:5, 1704:15,

1707:24, 1714:15,

1729:32, 1730:35,

1734:16, 1734:31,

1738:21, 1746:42,

1751:31, 1754:42,

1761:44, 1787:13,

1790:37, 1792:17,

1799:42, 1800:10,

1802:1, 1802:32,

1802:43

merits [3] - 1698:24,

1698:27, 1698:30

met [4] - 1727:15,

1728:1, 1728:16,

1731:21

methodology [2] -

1783:37, 1802:39

methods [2] -

1773:41, 1788:35

metrics [6] - 1723:20,

1730:16, 1730:19,

1735:32, 1747:31,

1749:3

micro [2] - 1774:2,

1774:9

micro-simulation [2] -

1774:2, 1774:9

microphone [1] -

1710:35

middle [1] - 1759:34

Midwifery [1] -

1715:29

might [38] - 1704:25,

1710:22, 1716:28,

1720:17, 1723:30,

1725:14, 1725:24,

1725:26, 1725:27,

1725:30, 1726:8,

1726:16, 1730:12,

1743:35, 1744:5,

1744:29, 1745:15,

1745:43, 1746:8,

1746:40, 1748:26,

1748:39, 1750:45,

1751:13, 1752:43,

1753:19, 1761:38,

1763:2, 1763:7,

1765:43, 1767:18,

1767:25, 1780:10,

1780:11, 1780:43,

1793:22, 1797:25,

1799:35

mightn't [1] - 1801:21

million [2] - 1731:4,

1731:25

mind [3] - 1763:20,

1764:24, 1800:30

Minister [12] -

1718:21, 1738:45,

1739:46, 1740:45,

1741:3, 1741:8,

1741:13, 1741:40,

1745:42, 1745:45,

1756:3, 1757:1

Minister's [1] -

1745:42

ministerial [4] -

1738:11, 1738:14,

1799:43, 1800:19

Ministers [1] -

1777:37

Ministries [1] -

1763:35

Ministry [2] - 1738:1,

1763:25

minute [3] - 1755:28,

1755:31, 1803:36

minutes [2] - 1716:31,

1716:36

mirror [1] - 1758:4

misaligned [1] -

1784:17

miss [3] - 1729:17,

1729:18, 1777:19

missed [2] - 1785:11,

1799:35

misses [2] - 1747:9,

1747:11

missing [7] - 1706:27,

1709:6, 1709:14,

1711:33, 1751:33,

1759:34, 1770:38

mitigate [1] - 1779:38

mix [2] - 1778:10,

1796:45

Mobile [1] - 1739:15

mobilise [2] - 1708:7,

1709:25

mobilised [1] -

1711:18

mobilises [1] -

1712:32

model [44] - 1700:19,

1704:24, 1711:28,

1720:37, 1721:2,

1724:23, 1731:7,

1731:45, 1732:17,

1732:19, 1732:20,

1732:41, 1738:46,

1738:47, 1743:3,

1743:5, 1752:24,

1755:3, 1761:41,

1766:26, 1772:30,

1773:17, 1774:23,

1778:12, 1780:34,

1786:1, 1786:3,

1786:14, 1788:28,

1789:17, 1789:18,

1790:23, 1791:34,

1791:41, 1792:12,

1795:41, 1796:9,

1796:16, 1796:17,

1796:40, 1797:19,

1797:25, 1801:20,

1802:33

models [35] - 1720:23,

1720:29, 1721:10,

1721:12, 1721:20,

1730:29, 1732:24,

1733:1, 1733:15,

1751:18, 1756:41,

1761:18, 1761:19,

1761:20, 1761:22,

1761:23, 1761:42,

1762:4, 1762:7,

1771:23, 1773:19,

1777:6, 1788:36,

1788:45, 1789:4,

1789:11, 1789:24,

1796:9, 1796:35,

1797:8, 1797:15,

1802:20, 1802:25,

1803:39

moderate [1] -

1700:39

moderate-to-severe

[1] - 1700:39

modern [1] - 1762:22

modernise [1] -

1754:28

modified [2] -

1719:29, 1751:23

moment [20] -

1708:14, 1721:29,

1724:33, 1725:39,

1726:35, 1726:37,

1735:28, 1754:25,

1759:27, 1760:27,

1764:27, 1765:14,

1778:28, 1781:45,

1784:21, 1787:11,

1788:17, 1792:18,

1793:34, 1802:19

momentum [2] -

1799:28, 1800:17

Monash [1] - 1732:39

money [13] - 1702:41,

1724:35, 1724:36,

1724:47, 1725:2,

1725:21, 1733:21,

1734:23, 1734:25,

1776:36, 1776:46,

1785:35, 1796:23

Monitor [1] - 1782:35

monitor [5] - 1701:35,

1702:24, 1730:1,

1748:23, 1783:5

monitored [2] -

1730:4, 1793:12

monitoring [14] -

.25/07/2019 (18)


20

1699:13, 1701:8,

1701:21, 1702:15,

1702:35, 1702:36,

1723:14, 1723:19,

1762:17, 1762:23,

1775:41, 1776:5,

1783:13, 1800:5

month [3] - 1714:18,

1714:22, 1802:40

months [12] - 1714:10,

1714:27, 1715:24,

1727:36, 1728:5,

1731:25, 1731:42,

1736:1, 1782:36,

1788:29, 1800:32

morning [3] - 1697:1,

1716:25, 1779:34

Mornington [2] -

1726:43, 1726:47

most [17] - 1699:36,

1702:10, 1705:39,

1707:30, 1710:45,

1712:43, 1724:30,

1745:37, 1754:1,

1758:15, 1768:27,

1777:10, 1778:30,

1781:17, 1785:1,

1786:23, 1794:44

mount [1] - 1708:4

move [5] - 1707:45,

1722:28, 1751:23,

1752:12, 1787:6

moved [3] - 1737:30,

1739:5, 1743:9

movement [1] -

1794:45

moving [5] - 1711:30,

1738:25, 1738:47,

1746:21, 1767:18

MS [19] - 1697:1,

1697:7, 1710:19,

1710:34, 1713:3,

1713:10, 1713:15,

1734:13, 1736:28,

1736:39, 1736:44,

1752:18, 1755:20,

1755:28, 1755:35,

1755:40, 1801:29,

1804:5, 1804:12

multidisciplinary [1] -

1790:26

multiple [7] - 1699:33,

1751:32, 1763:33,

1781:19, 1781:20,

1788:10, 1788:27

must [9] - 1698:11,

1703:26, 1703:45,

1704:12, 1705:29,

1706:37, 1709:26,

1731:32, 1776:13

N

naively [1] - 1727:20

name [1] - 1727:46

named [2] - 1710:7,

1760:4

narrative [1] - 1769:12

narrow [2] - 1709:41,

1777:40

nascent [1] - 1711:1

national [10] -

1740:10, 1740:14,

1740:19, 1740:20,

1747:35, 1747:44,

1767:31, 1768:38,

1793:46, 1803:2

National [5] - 1751:31,

1765:35, 1777:34,

1794:14, 1803:37

nationally [2] -

1785:41, 1785:47

natural [1] - 1707:19

nature [4] - 1712:13,

1726:5, 1735:44,

1772:47

navigate [3] - 1733:9,

1733:10, 1733:12

navigating [1] -

1720:28

NDIS [1] - 1803:20

near [1] - 1798:17

nearing [1] - 1766:11

nearly [1] - 1746:47

necessarily [1] -

1707:20

necessary [10] -

1700:4, 1702:22,

1748:43, 1751:41,

1776:14, 1780:5,

1782:38, 1783:39,

1799:43, 1800:3

need [71] - 1700:46,

1703:28, 1703:40,

1703:41, 1704:22,

1706:25, 1708:41,

1711:40, 1721:15,

1721:18, 1721:23,

1721:33, 1721:34,

1722:38, 1723:10,

1724:24, 1726:4,

1726:10, 1726:21,

1726:22, 1726:38,

1727:31, 1732:4,

1742:3, 1744:5,

1745:7, 1745:38,

1746:2, 1746:39,

1747:46, 1750:8,

1750:14, 1750:16,

1750:18, 1750:21,

1751:1, 1752:10,

1752:43, 1755:9,

1757:24, 1758:27,

1759:38, 1760:16,

1760:26, 1761:37,

1762:5, 1762:21,

1765:11, 1765:32,

1765:38, 1769:15,

1770:14, 1770:45,

1770:47, 1771:6,

1774:34, 1774:35,

1774:37, 1780:32,

1781:21, 1783:3,

1784:40, 1786:13,

1786:31, 1789:2,

1793:9, 1796:34,

1799:22, 1800:31,

1802:9

needed [19] - 1731:46,

1739:12, 1740:18,

1740:37, 1740:42,

1740:44, 1741:18,

1742:29, 1743:5,

1749:31, 1750:13,

1753:10, 1770:1,

1778:6, 1782:26,

1785:36, 1798:17,

1798:18

needing [2] - 1753:1,

1779:7

needs [34] - 1700:20,

1701:22, 1712:21,

1721:35, 1723:27,

1726:22, 1730:18,

1742:9, 1742:22,

1742:23, 1745:34,

1745:46, 1753:4,

1754:28, 1757:4,

1760:47, 1761:43,

1763:33, 1763:39,

1766:16, 1768:21,

1768:28, 1770:2,

1770:10, 1779:1,

1780:13, 1780:37,

1782:44, 1789:17,

1789:43, 1792:28,

1796:3, 1796:5,

1802:13

negotiated [1] -

1750:22

negotiating [1] -

1729:28

net [2] - 1749:30,

1749:47

network [2] - 1789:30,

1802:40

Networks [3] -

1765:36, 1789:44,

1801:12

networks [1] -

1802:38

never [4] - 1734:4,

1739:32, 1741:43,

1784:5

nevertheless [3] -

1711:24, 1777:45,

1797:5

new [22] - 1705:46,

1707:1, 1707:10,

1708:1, 1708:35,

1719:9, 1731:8,

1731:26, 1733:6,

1739:11, 1741:20,

1742:16, 1745:7,

1761:25, 1767:31,

1787:21, 1787:45,

1800:25, 1802:40,

1803:46

New [8] - 1707:28,

1708:31, 1710:42,

1710:45, 1711:6,

1711:13, 1711:24,

1770:24

next [14] - 1697:1,

1713:10, 1724:5,

1736:29, 1736:39,

1744:42, 1755:35,

1764:23, 1790:8,

1793:43, 1793:47,

1800:32, 1803:36,

1803:38

Next [1] - 1767:29

NGOs [2] - 1739:17,

1752:5

nice [1] - 1727:30

Nichols [1] - 1696:34

NICHOLS [10] -

1697:1, 1697:7,

1710:19, 1710:34,

1713:3, 1755:35,

1755:40, 1801:29,

1804:5, 1804:12

night [1] - 1724:25

nobly [1] - 1762:36

nobody's [1] -

1729:23

non [4] - 1746:34,

1746:41, 1755:4,

1757:41

non-acute [1] -

1757:41

non-clinical [1] -

1755:4

non-salary [2] -

1746:34, 1746:41

none [1] - 1735:25

nonetheless [2] -

1730:44, 1777:3

normal [2] - 1707:18,

1744:36

northern [1] - 1752:39

Northern [38] -

1737:2, 1737:11,

1742:36, 1742:39,

1742:40, 1742:44,

1743:6, 1743:9,

1743:10, 1743:16,

1743:27, 1743:38,

1743:42, 1743:45,

1744:7, 1744:9,

1744:11, 1744:47,

1747:25, 1750:3,

1750:18, 1750:24,

1750:36, 1750:39,

1751:4, 1752:25,

1752:30, 1752:32,

1753:3, 1753:6,

1753:17, 1753:20,

1753:23, 1753:26,

1753:31, 1753:38,

1753:41, 1753:45

Northern's [1] -

1743:3

note [4] - 1703:47,

1758:11, 1783:7,

1787:10

notice [3] - 1765:3,

1792:44, 1803:30

noting [2] - 1790:46,

1799:24

notion [1] - 1797:12

notwithstanding [1] -

1735:44

November [3] -

1755:44, 1779:15,

1790:44

nowhere [2] -

1726:34, 1727:4

nuanced [1] - 1791:35

number [30] -

1703:32, 1705:35,

1706:35, 1711:39,

1712:43, 1715:4,

1717:32, 1720:6,

1723:19, 1724:1,

1729:15, 1729:22,

1737:16, 1738:38,

1739:31, 1744:15,

1747:33, 1751:3,

1752:21, 1752:41,

1755:47, 1757:38,

1760:35, 1761:32,

1764:2, 1771:17,

1781:40, 1783:9,

1792:15, 1799:18

numbers [8] -

1721:12, 1721:14,

1726:37, 1744:28,

1758:28, 1764:42,

1769:41, 1770:3

.25/07/2019 (18)


21

numeric [4] - 1709:37,

1780:8, 1780:27,

1780:28

numerous [1] - 1796:7

nurse [1] - 1713:43

Nursing [4] - 1713:24,

1713:27, 1713:30,

1715:29

O

o'clock [1] - 1716:25

objective [8] -

1698:41, 1698:42,

1700:34, 1700:35,

1705:3, 1718:1,

1769:18, 1792:26

objectives [13] -

1698:28, 1698:30,

1717:17, 1717:31,

1717:35, 1717:38,

1717:41, 1718:4,

1718:7, 1718:23,

1719:10, 1719:11,

1763:43

obligated [1] -

1749:44

observation [5] -

1708:27, 1710:1,

1720:10, 1771:26,

1785:13

observations [7] -

1709:47, 1716:3,

1740:31, 1746:21,

1747:18, 1751:8,

1772:16

observed [1] - 1765:2

obtain [2] - 1703:11,

1703:42

obtaining [1] -

1703:39

obvious [3] - 1710:46,

1731:21, 1781:4

obviously [13] -

1705:6, 1706:25,

1711:36, 1740:2,

1741:23, 1744:27,

1745:36, 1750:26,

1753:9, 1764:32,

1779:9, 1795:24,

1804:2

occasion [2] -

1725:24, 1775:25

occupancy [2] -

1771:35, 1771:42

occupational [2] -

1717:37, 1722:4

occupy [1] - 1764:4

occupying [1] -

1771:47

occur [11] - 1711:40,

1742:4, 1743:29,

1745:37, 1748:16,

1751:28, 1753:30,

1753:37, 1753:39,

1758:43, 1783:22

occurred [5] -

1716:28, 1751:8,

1779:18, 1798:47

occurring [3] -

1739:20, 1751:23,

1753:42

occurs [2] - 1745:21,

1750:41

October [1] - 1790:42

off-line [1] - 1764:22

offending [1] -

1757:44

offer [1] - 1731:39

Office [2] - 1697:16,

1745:43

office [7] - 1697:42,

1697:44, 1698:32,

1711:47, 1738:11,

1764:4, 1771:47

Officer [5] - 1713:20,

1714:23, 1715:13,

1715:19, 1750:21

officer [3] - 1697:37,

1698:6, 1698:20

officials [2] - 1767:21,

1800:20

offset [3] - 1725:18,

1725:34, 1726:5

often [20] - 1700:9,

1701:26, 1702:12,

1702:38, 1719:43,

1726:12, 1726:14,

1726:15, 1730:9,

1730:10, 1731:20,

1738:12, 1745:42,

1747:6, 1753:18,

1753:40, 1758:18,

1785:9, 1795:12,

1800:46

old [2] - 1754:5,

1802:40

once [2] - 1731:29,

1799:31

one [73] - 1701:19,

1701:34, 1702:14,

1703:21, 1704:16,

1705:10, 1705:27,

1706:47, 1707:32,

1708:43, 1711:6,

1716:2, 1717:28,

1721:42, 1723:3,

1723:18, 1723:36,

1725:1, 1727:36,

1728:18, 1728:23,

1730:34, 1731:13,

1731:42, 1732:2,

1739:19, 1739:39,

1741:2, 1741:30,

1746:2, 1748:20,

1752:2, 1752:13,

1752:30, 1753:20,

1753:29, 1758:7,

1766:5, 1767:19,

1771:7, 1773:13,

1773:29, 1773:37,

1774:26, 1775:15,

1775:32, 1776:30,

1777:45, 1779:12,

1779:42, 1780:16,

1781:28, 1781:45,

1782:25, 1783:26,

1785:41, 1787:22,

1789:21, 1789:41,

1789:42, 1791:13,

1791:17, 1791:18,

1792:32, 1793:12,

1793:24, 1796:26,

1799:19, 1801:32,

1801:44, 1803:36,

1804:3

One [1] - 1766:13

ones [2] - 1705:2,

1753:14

ongoing [3] - 1704:16,

1786:11, 1800:27

online [1] - 1776:34

operate [4] - 1701:4,

1739:16, 1746:44,

1772:13

operates [1] - 1762:40

Operating [3] -

1715:13, 1715:19,

1750:21

operating [1] -

1710:32

operation [1] -

1697:40

Operational [1] -

1734:5

operational [8] -

1703:5, 1703:11,

1714:8, 1729:27,

1745:15, 1784:37,

1784:38, 1801:8

operations [1] -

1714:33

opportunities [9] -

1754:26, 1767:19,

1770:39, 1785:11,

1796:26, 1799:33,

1799:35, 1803:47,

1804:2

opportunity [11] -

1711:37, 1714:21,

1715:21, 1719:25,

1728:9, 1757:9,

1765:41, 1777:5,

1784:41, 1792:5,

1803:38

opposed [2] -

1773:45, 1773:46

optimal [1] - 1778:9

optimise [2] - 1750:5,

1762:14

optimised [1] -

1750:46

optimistic [1] - 1779:5

optimum [1] - 1760:29

options [4] - 1740:3,

1795:7, 1795:37,

1797:38

order [7] - 1701:32,

1701:38, 1764:1,

1764:7, 1774:34,

1793:31, 1800:29

organisation [13] -

1711:19, 1715:22,

1715:47, 1716:37,

1716:42, 1716:44,

1717:15, 1718:12,

1720:7, 1724:12,

1724:40, 1727:31,

1747:44

organisational [1] -

1715:45

organisations [1] -

1747:43

organises [1] -

1706:21

oriented [3] - 1756:40,

1771:4, 1782:3

originally [1] -

1797:19

otherwise [2] -

1717:7, 1759:45

ought [1] - 1779:36

ourselves [3] -

1702:4, 1706:9,

1730:28

outcome [36] -

1705:34, 1705:35,

1706:8, 1706:13,

1706:26, 1707:19,

1707:32, 1707:33,

1707:37, 1707:41,

1707:44, 1708:1,

1708:2, 1708:5,

1708:10, 1708:11,

1708:12, 1708:38,

1711:18, 1711:19,

1711:20, 1721:21,

1721:35, 1722:17,

1723:5, 1723:7,

1730:12, 1733:20,

1747:36, 1762:44,

1763:11, 1776:29,

1779:31, 1782:3,

1785:45

outcome-oriented [1]

- 1782:3

outcomes [65] -

1699:24, 1700:29,

1702:47, 1703:42,

1705:37, 1705:40,

1705:43, 1705:44,

1705:46, 1705:47,

1706:19, 1706:20,

1706:24, 1706:38,

1706:43, 1707:2,

1707:6, 1707:10,

1707:15, 1707:16,

1707:31, 1708:13,

1708:18, 1708:20,

1708:25, 1708:33,

1708:41, 1709:2,

1709:7, 1709:8,

1709:11, 1709:14,

1709:22, 1709:23,

1711:2, 1711:13,

1711:34, 1721:44,

1724:2, 1747:38,

1748:22, 1756:37,

1760:31, 1761:13,

1768:35, 1768:40,

1768:46, 1769:5,

1769:6, 1769:13,

1769:19, 1769:22,

1773:1, 1774:4,

1775:41, 1776:5,

1777:47, 1778:5,

1780:2, 1780:37,

1781:9, 1781:22,

1782:7, 1803:1

outline [2] - 1737:5,

1778:9

outlined [2] - 1699:14,

1740:21

outpatient [2] -

1724:37, 1797:12

outpatients [1] -

1723:39

output [6] - 1706:8,

1706:34, 1706:43,

1708:42, 1708:47,

1709:1

outputs [14] -

1706:36, 1706:39,

1707:7, 1707:12,

1708:17, 1708:21,

1708:23, 1708:44,

1708:46, 1708:47,

1709:18, 1711:1,

1733:20

.25/07/2019 (18)


22

outset [2] - 1766:41,

1800:42

outside [2] - 1744:22,

1778:21

outsourced [1] -

1743:14

outweigh [1] -

1710:16

over-emphasis [2] -

1780:16, 1780:20

over-representation

[1] - 1794:26

overall [8] - 1698:47,

1699:5, 1700:42,

1700:43, 1709:13,

1744:46, 1746:6,

1788:3

overarching [6] -

1705:36, 1711:34,

1712:15, 1779:8,

1789:38, 1791:11

overcome [1] -

1787:31

overdose [1] - 1753:8

overrun [3] - 1725:18,

1725:34, 1726:6

overseeing [1] -

1715:20

overseen [1] -

1715:12

oversight [16] -

1698:8, 1698:11,

1701:8, 1702:16,

1702:19, 1702:24,

1703:35, 1703:37,

1703:39, 1704:13,

1704:23, 1722:28,

1733:2, 1782:23,

1788:8, 1791:12

oversighting [1] -

1702:36

overtaken [1] - 1712:9

overview [2] -

1710:23, 1752:22

own [11] - 1704:9,

1717:31, 1728:41,

1732:26, 1734:34,

1742:46, 1743:12,

1753:21, 1762:36,

1797:1

own-source [1] -

1728:41

owner [2] - 1701:47,

1703:26

P

p.10 [1] - 1765:17

p.208 [1] - 1706:47

pace [3] - 1785:19,

1799:21, 1799:26

package [1] - 1740:24

packages [1] -

1796:30

page [16] - 1728:34,

1759:28, 1759:29,

1765:47, 1766:10,

1766:11, 1766:30,

1767:17, 1767:26,

1767:45, 1767:46,

1768:16, 1768:34,

1769:30, 1770:30,

1771:26

paid [1] - 1699:43

pain [1] - 1730:17

panel [1] - 1737:23

paper [1] - 1770:47

Paper [2] - 1706:42,

1708:24

paragraph [11] -

1699:3, 1718:28,

1719:33, 1738:8,

1738:34, 1742:36,

1744:43, 1751:9,

1757:14, 1765:12,

1779:26

parallel [2] - 1777:30,

1784:42

parallels [1] - 1723:13

parameters [2] -

1746:44, 1772:12

paramount [1] -

1741:27

parity [4] - 1787:30,

1798:23, 1798:25,

1798:36

Parliament [8] -

1697:37, 1697:39,

1698:5, 1698:6,

1698:20, 1745:44,

1745:45, 1746:13

Part [1] - 1766:13

part [25] - 1706:27,

1707:32, 1724:30,

1733:41, 1735:31,

1738:29, 1744:20,

1745:21, 1761:7,

1765:32, 1772:17,

1776:1, 1778:13,

1780:16, 1786:14,

1786:17, 1786:30,

1786:32, 1787:34,

1791:40, 1793:17,

1793:45, 1795:24,

1801:4, 1802:28

partial [3] - 1783:30,

1783:32, 1786:39

partially [1] - 1792:10

participant [1] -

1751:27

participate [1] -

1734:6

particular [17] -

1715:8, 1721:33,

1732:13, 1736:17,

1742:23, 1744:44,

1748:20, 1749:8,

1749:14, 1752:24,

1757:18, 1762:36,

1762:41, 1764:41,

1778:37, 1792:24,

1801:26

particularly [13] -

1705:18, 1705:23,

1709:19, 1731:14,

1734:17, 1747:22,

1763:32, 1782:14,

1790:9, 1796:29,

1798:40, 1798:41,

1803:11

parties [1] - 1780:33

partly [1] - 1726:40

partners [1] - 1767:3

parts [18] - 1703:4,

1742:16, 1745:22,

1752:2, 1762:10,

1766:45, 1769:14,

1774:33, 1780:3,

1780:4, 1780:17,

1781:20, 1788:32,

1796:7, 1797:9,

1797:40, 1799:30,

1801:10

past [8] - 1728:4,

1730:33, 1730:36,

1744:44, 1770:36,

1786:29, 1801:11,

1801:16

path [1] - 1803:27

pathway [2] - 1732:37,

1797:13

pathways [1] -

1793:10

patient [23] - 1726:22,

1728:42, 1735:11,

1743:47, 1747:39,

1749:17, 1749:22,

1749:27, 1753:6,

1753:7, 1753:8,

1753:9, 1753:13,

1753:20, 1753:27,

1753:34, 1754:7,

1794:21, 1795:3,

1795:6, 1795:21,

1796:34

patients [37] -

1716:29, 1721:12,

1721:13, 1743:44,

1743:46, 1744:2,

1744:5, 1744:8,

1744:11, 1744:18,

1744:25, 1744:31,

1744:33, 1749:13,

1749:27, 1749:28,

1749:29, 1749:47,

1750:1, 1750:9,

1752:43, 1753:26,

1753:29, 1753:31,

1753:47, 1754:3,

1754:4, 1754:11,

1757:30, 1757:39,

1792:29, 1794:26,

1794:37, 1794:44,

1795:9, 1795:30,

1795:42

Paul [1] - 1703:24

pause [1] - 1782:36

pay [2] - 1703:24

pays [1] - 1700:4

Peake [26] - 1709:32,

1755:36, 1755:40,

1756:29, 1757:12,

1759:27, 1763:14,

1764:18, 1765:11,

1765:41, 1766:1,

1767:25, 1768:16,

1770:14, 1771:45,

1773:27, 1783:7,

1794:12, 1797:32,

1798:20, 1800:41,

1801:29, 1801:30,

1801:32, 1804:5,

1804:8

PEAKE [1] - 1755:38

peer [1] - 1755:4

Peninsula [30] -

1713:20, 1714:24,

1714:26, 1714:34,

1714:40, 1715:12,

1715:24, 1716:16,

1717:6, 1718:15,

1718:35, 1719:28,

1720:5, 1720:27,

1722:2, 1722:23,

1724:6, 1726:34,

1729:35, 1730:46,

1731:24, 1731:33,

1732:21, 1732:30,

1732:39, 1733:28,

1733:41, 1734:33,

1735:28, 1735:38

Peninsula's [1] -

1717:2

Penny [1] - 1696:26

people [77] - 1700:39,

1700:44, 1701:17,

1701:22, 1701:42,

1705:20, 1707:15,

1707:37, 1707:40,

1708:40, 1720:44,

1724:14, 1726:35,

1726:41, 1727:31,

1728:21, 1728:24,

1728:26, 1729:17,

1729:18, 1730:8,

1730:11, 1730:26,

1731:30, 1731:38,

1732:30, 1733:16,

1733:18, 1738:41,

1738:43, 1739:31,

1739:43, 1740:1,

1740:40, 1740:43,

1741:11, 1746:17,

1747:8, 1754:5,

1754:6, 1754:45,

1755:6, 1755:8,

1757:7, 1757:44,

1757:46, 1758:4,

1759:36, 1759:44,

1760:43, 1761:13,

1761:44, 1762:47,

1763:1, 1763:32,

1766:35, 1766:40,

1768:4, 1770:4,

1770:7, 1775:21,

1782:15, 1783:19,

1784:18, 1786:10,

1788:18, 1788:21,

1790:6, 1790:18,

1791:38, 1794:26,

1795:43, 1796:27,

1796:44, 1800:21,

1801:34, 1802:17

peoples' [1] - 1709:40

per [16] - 1707:39,

1707:46, 1708:5,

1711:20, 1714:4,

1728:38, 1728:45,

1728:47, 1752:37,

1769:35, 1776:28,

1797:45

perception [2] -

1798:37, 1799:9

perfect [1] - 1760:27

perform [1] - 1761:32

Performance [2] -

1697:21, 1762:17

performance [59] -

1697:45, 1698:18,

1699:25, 1701:8,

1701:34, 1701:35,

1702:31, 1703:40,

1703:41, 1704:12,

1704:23, 1704:31,

1704:37, 1705:9,

1705:15, 1705:26,

1705:28, 1706:6,

1707:29, 1721:22,

1721:44, 1722:31,

.25/07/2019 (18)


23

1722:45, 1723:20,

1723:36, 1724:7,

1727:16, 1727:47,

1728:19, 1729:21,

1729:22, 1729:33,

1735:32, 1736:10,

1744:14, 1744:16,

1744:22, 1747:19,

1748:1, 1762:23,

1765:25, 1768:38,

1769:13, 1775:21,

1782:7, 1782:9,

1782:12, 1783:38,

1792:6, 1793:16,

1793:33, 1793:39,

1793:46, 1794:10,

1800:7, 1803:40

performing [2] -

1749:3, 1752:14

perhaps [12] -

1702:44, 1703:34,

1715:25, 1718:15,

1719:5, 1727:20,

1730:26, 1739:22,

1742:29, 1743:32,

1744:41, 1761:28

Perhaps [1] - 1791:17

period [12] - 1714:20,

1714:22, 1735:12,

1736:8, 1750:26,

1764:5, 1769:37,

1772:1, 1794:36,

1796:10, 1797:6,

1797:43

periods [4] - 1744:26,

1794:27, 1795:44,

1801:1

permitted [1] -

1698:23

persist [1] - 1796:10

persistence [1] -

1800:47

person [4] - 1728:18,

1732:29, 1749:31,

1756:39

person-centred [1] -

1756:39

personal [1] - 1722:19

personality [1] -

1798:42

personnel [1] -

1782:44

persons' [1] - 1790:3

perspective [7] -

1718:22, 1719:17,

1751:9, 1762:45,

1778:34, 1779:43,

1780:1

perspectives [3] -

1771:5, 1790:20,

1790:21

perverse [3] -

1709:41, 1710:9,

1780:24

perversely [2] -

1780:10, 1780:14

Peter [1] - 1703:24

phase [1] - 1744:42

phased [1] - 1802:14

phases [3] - 1796:33,

1796:34, 1796:39

philosophy [1] -

1766:26

PHNs [1] - 1785:7

physical [28] -

1718:30, 1721:25,

1722:47, 1723:8,

1723:13, 1723:14,

1723:28, 1723:34,

1725:2, 1725:21,

1726:19, 1726:35,

1730:16, 1732:36,

1732:38, 1733:11,

1734:44, 1735:1,

1735:4, 1735:7,

1736:6, 1736:11,

1785:34, 1785:37,

1787:30, 1797:9,

1797:14, 1798:24

physicians [1] -

1753:27

pick [1] - 1748:39

picking [1] - 1785:13

picture [2] - 1732:21,

1765:30

piece [6] - 1723:9,

1770:24, 1774:19,

1779:19, 1788:27,

1802:43

pieces [4] - 1724:26,

1731:3, 1731:6,

1777:44

pilot [1] - 1783:17

pilots [3] - 1783:27,

1783:29, 1801:43

place [20] - 1703:21,

1718:45, 1727:7,

1736:11, 1742:8,

1742:12, 1742:24,

1749:9, 1752:25,

1754:32, 1769:23,

1777:45, 1777:47,

1780:34, 1782:13,

1796:24, 1796:45,

1797:29, 1800:18,

1800:36

placed [6] - 1703:22,

1703:25, 1757:18,

1763:39, 1773:7,

1799:14

places [2] - 1731:35,

1785:36

Plan [17] - 1751:32,

1765:3, 1765:35,

1767:29, 1769:23,

1777:10, 1777:15,

1777:32, 1777:35,

1778:17, 1778:47,

1779:35, 1782:3,

1782:21, 1782:32,

1783:11, 1803:37

plan [75] - 1699:14,

1699:16, 1699:19,

1699:25, 1704:37,

1705:6, 1705:34,

1705:44, 1705:45,

1709:7, 1712:38,

1712:42, 1712:45,

1717:3, 1717:13,

1717:14, 1717:16,

1717:17, 1717:24,

1717:31, 1717:33,

1718:12, 1718:13,

1718:36, 1718:43,

1718:44, 1719:5,

1719:6, 1719:8,

1719:9, 1719:11,

1719:13, 1719:14,

1731:19, 1737:23,

1740:10, 1740:14,

1740:19, 1740:20,

1740:21, 1740:29,

1752:10, 1765:4,

1765:7, 1766:33,

1766:39, 1767:7,

1767:31, 1767:38,

1767:40, 1768:12,

1770:3, 1777:18,

1777:31, 1777:46,

1778:2, 1778:4,

1778:9, 1778:21,

1778:22, 1778:29,

1778:33, 1778:35,

1778:36, 1778:40,

1778:42, 1779:9,

1779:13, 1782:23,

1786:37, 1802:2,

1803:45

planned [1] - 1705:29

Planning [1] - 1756:10

planning [19] -

1699:12, 1699:37,

1703:13, 1761:36,

1764:1, 1767:4,

1768:18, 1768:20,

1770:18, 1775:38,

1775:39, 1777:10,

1777:35, 1785:26,

1787:7, 1787:35,

1788:3, 1789:39,

1799:22

plans [10] - 1709:9,

1718:46, 1719:21,

1731:43, 1740:17,

1751:32, 1751:34,

1751:37, 1751:39,

1777:30

platform [1] - 1782:39

play [2] - 1760:36,

1766:45

plays [3] - 1761:7,

1763:25, 1795:32

plight [1] - 1740:40

PM [1] - 1724:25

point [40] - 1701:44,

1704:20, 1710:46,

1711:3, 1711:13,

1711:25, 1716:23,

1716:41, 1722:3,

1722:11, 1724:19,

1725:5, 1725:38,

1727:14, 1729:7,

1729:26, 1767:27,

1767:47, 1769:11,

1769:18, 1770:21,

1771:39, 1773:28,

1775:7, 1778:35,

1779:17, 1779:46,

1780:36, 1781:20,

1781:28, 1785:14,

1788:26, 1791:23,

1791:35, 1794:29,

1796:17, 1798:39,

1800:11, 1802:23,

1803:4

pointed [1] - 1759:22

pointers [1] - 1711:32

pointing [1] - 1763:22

points [7] - 1721:5,

1721:6, 1764:9,

1764:28, 1772:28,

1779:42, 1781:44

police [9] - 1739:24,

1739:39, 1739:40,

1739:47, 1740:1,

1740:5, 1740:35,

1755:5, 1803:6

policies [1] - 1739:8

policy [15] - 1698:24,

1698:28, 1698:30,

1702:23, 1702:41,

1705:36, 1741:5,

1760:14, 1763:34,

1791:44, 1795:28,

1795:31, 1795:35,

1803:18

Policy [1] - 1756:15

political [6] - 1707:18,

1741:46, 1772:44,

1786:19, 1798:4,

1801:24

politically [2] -

1739:30, 1786:28

poor [3] - 1731:47,

1747:5, 1748:21

poorest [1] - 1752:13

poorly [2] - 1731:41,

1753:46

populated [3] -

1769:25, 1769:27,

1781:36

population [24] -

1700:15, 1700:21,

1707:40, 1708:15,

1743:12, 1752:38,

1760:18, 1764:39,

1766:17, 1768:17,

1768:46, 1769:35,

1769:44, 1770:2,

1770:15, 1770:18,

1770:19, 1773:23,

1776:26, 1776:42,

1789:2, 1794:16,

1794:17, 1796:2

Population [1] -

1768:44

population-level [1] -

1789:2

populations [1] -

1700:1

portal [1] - 1774:39

portfolio [6] -

1716:10, 1716:11,

1741:9, 1741:41,

1741:42, 1802:28

portfolios [1] -

1715:22

portion [2] - 1718:27,

1728:32

Portsea [1] - 1714:41

posed [1] - 1729:3

position [1] - 1704:18

positions [3] -

1725:29, 1726:26,

1726:32

positive [2] - 1766:27,

1787:41

positively [1] -

1765:34

possible [2] -

1744:28, 1760:21

post [1] - 1786:2

potentially [1] -

1784:42

power [2] - 1704:9,

1704:10

powerful [1] - 1781:17

powerfully [1] -

1757:3

practical [7] -

.25/07/2019 (18)


24

1766:44, 1773:6,

1774:3, 1774:26,

1795:31, 1795:32,

1799:38

practice [10] -

1702:11, 1710:31,

1710:42, 1710:47,

1711:28, 1711:46,

1730:29, 1732:31,

1756:41, 1788:28

practitioners [1] -

1801:17

pre [2] - 1752:14,

1794:30

pre-eminent [1] -

1752:14

pre-existing [1] -

1794:30

precede [1] - 1792:39

preceded [1] -

1707:30

preceding [1] -

1792:33

precise [1] - 1792:45

precludes [1] -

1698:26

predecessors [1] -

1776:13

predicated [1] -

1703:39

predictability [1] -

1796:39

predicted [1] -

1799:34

predictions [2] -

1769:31, 1776:8

predominant [1] -

1705:2

predominantly [3] -

1701:19, 1734:19,

1792:10

prefer [1] - 1769:7

premature [1] -

1750:44

Premier [4] - 1705:40,

1741:23, 1756:16,

1757:1

preparation [1] -

1717:7

prepared [4] -

1697:30, 1741:6,

1741:8, 1756:24

preparing [1] -

1728:33

prescription [1] -

1789:22

present [9] - 1702:30,

1702:31, 1743:44,

1743:46, 1749:13,

1752:42, 1755:7,

1769:19, 1778:28

presentations [3] -

1752:32, 1757:24,

1794:16

presented [5] -

1722:4, 1741:36,

1746:5, 1748:42,

1782:17

presently [2] - 1709:6,

1774:6

presents [1] - 1794:20

President [1] -

1756:20

pressing [2] -

1778:30, 1778:46

pressure [13] -

1735:6, 1735:7,

1735:10, 1735:11,

1735:13, 1757:18,

1757:21, 1757:31,

1772:23, 1798:6,

1798:10, 1802:16,

1802:18

Pressure [1] - 1757:28

pressures [8] -

1732:11, 1745:35,

1770:15, 1770:28,

1771:17, 1771:29,

1795:18, 1801:36

pretty [7] - 1722:33,

1743:38, 1797:14,

1798:8, 1798:14,

1800:38, 1803:31

prevalence [1] -

1768:47

prevent [2] - 1700:37,

1763:1

preventing [1] -

1784:18

Prevention [3] -

1767:29, 1777:32,

1803:46

prevention [6] -

1706:14, 1767:30,

1767:35, 1789:40,

1803:45, 1804:1

previous [9] -

1702:18, 1730:40,

1744:1, 1744:2,

1744:41, 1747:22,

1765:4, 1784:38,

1793:7

price [2] - 1699:43,

1700:4

prices [1] - 1762:7

Pricing [3] - 1737:18,

1751:24, 1796:32

Primary [3] - 1765:36,

1789:44, 1801:12

primary [4] - 1697:38,

1698:42, 1706:24,

1785:7

prime [1] - 1705:21

Prime [1] - 1756:2

principal [2] -

1767:20, 1773:36

principle [2] - 1800:35

principles [4] -

1758:20, 1761:1,

1771:18, 1771:24

priorities [6] - 1709:3,

1709:13, 1712:22,

1712:25, 1717:22,

1761:38

Priorities [37] -

1717:2, 1717:5,

1717:8, 1717:10,

1717:19, 1717:21,

1717:24, 1717:26,

1717:30, 1717:36,

1717:42, 1717:47,

1718:2, 1718:5,

1718:8, 1718:15,

1718:17, 1718:20,

1718:24, 1718:26,

1718:29, 1719:12,

1719:14, 1720:2,

1734:42, 1792:6,

1792:18, 1792:20,

1792:23, 1792:26,

1792:30, 1792:36,

1792:38, 1793:14,

1793:25, 1793:27,

1793:43

Priorities' [1] - 1722:3

prioritisation [11] -

1709:10, 1711:34,

1719:31, 1721:30,

1724:5, 1744:43,

1744:45, 1745:37,

1748:11, 1787:32,

1798:22

prioritise [3] -

1709:38, 1719:37,

1748:29

prioritised [3] -

1717:47, 1718:37,

1786:28

prioritising [3] -

1718:13, 1787:18,

1799:10

priority [15] - 1699:18,

1740:33, 1741:43,

1741:46, 1775:32,

1776:16, 1776:18,

1777:2, 1777:3,

1790:33, 1793:2,

1795:11, 1797:21,

1799:14

Priority [4] - 1723:42,

1728:7, 1782:1,

1793:4

privacy [1] - 1803:8

private [5] - 1702:11,

1728:42, 1770:11,

1770:12, 1801:16

problem [11] -

1701:27, 1702:44,

1720:37, 1727:35,

1739:26, 1764:27,

1769:36, 1785:15,

1791:44, 1795:43,

1798:16

problem" [1] -

1785:18

problematic [1] -

1738:13

Problems [1] - 1701:7

problems [15] -

1700:38, 1700:40,

1700:45, 1712:43,

1749:36, 1758:7,

1768:5, 1769:1,

1769:2, 1770:5,

1776:4, 1779:38,

1783:22, 1796:8,

1801:1

process [35] -

1708:29, 1708:37,

1709:26, 1716:20,

1717:9, 1717:11,

1717:24, 1717:30,

1718:13, 1719:7,

1719:20, 1721:4,

1721:17, 1721:26,

1722:13, 1722:45,

1724:10, 1724:12,

1724:13, 1724:17,

1724:32, 1724:39,

1732:41, 1736:11,

1737:21, 1745:9,

1745:24, 1745:30,

1745:31, 1774:9,

1774:11, 1782:27,

1795:28, 1796:40,

1797:32

processes [4] -

1717:42, 1723:35,

1783:39, 1791:44

procurement [1] -

1762:2

producing [1] -

1761:12

product [1] - 1720:38

productivity [1] -

1724:17

Productivity [2] -

1756:2, 1804:3

professional [1] -

1738:5

Professor [2] -

1696:27, 1696:29

profile [3] - 1723:47,

1726:8, 1726:21

profiles [1] - 1724:42

profoundly [1] -

1764:39

Program [4] -

1715:28, 1725:15,

1747:28, 1751:1

program [10] -

1697:47, 1715:31,

1725:44, 1725:45,

1732:46, 1741:20,

1750:20, 1750:22,

1751:3, 1783:46

programs [11] -

1720:27, 1724:40,

1725:32, 1725:42,

1726:3, 1726:36,

1731:2, 1732:47,

1766:34, 1783:16,

1783:19

progress [12] -

1699:21, 1699:35,

1699:41, 1705:30,

1710:15, 1743:29,

1750:42, 1760:42,

1780:47, 1781:36,

1783:5, 1799:28

progressed [2] -

1731:44, 1778:21

progressive [1] -

1770:34

progressively [1] -

1750:23

prohibition [1] -

1698:28

project [4] - 1774:1,

1782:28, 1782:46,

1787:35

projected [1] - 1770:3

projections [2] -

1770:18, 1770:20

projects [5] - 1745:15,

1745:16, 1787:38,

1787:44, 1803:10

promise [1] - 1773:10

promotion [1] -

1789:40

promulgated [2] -

1706:18, 1707:3

proper [5] - 1701:45,

1704:24, 1765:25,

1774:46, 1803:27

properly [7] - 1703:14,

1703:16, 1760:21,

1760:22, 1775:30,

1779:39, 1799:17

property [1] - 1781:13

.25/07/2019 (18)


25

proportion [1] -

1752:43

proposal [1] - 1750:3

proposals [2] -

1741:34, 1745:18

propose [1] - 1712:4

proposed [3] -

1700:27, 1768:39,

1786:4

proposition [1] -

1759:40

prospect [1] - 1801:11

protected [1] -

1740:43

protection [1] -

1772:40

protections [1] -

1803:7

protocols [1] -

1788:20

provide [34] - 1697:38,

1714:38, 1714:43,

1720:46, 1721:11,

1721:15, 1722:8,

1725:46, 1726:23,

1729:16, 1730:46,

1731:37, 1734:29,

1735:47, 1743:41,

1746:17, 1758:46,

1759:8, 1759:11,

1762:45, 1763:4,

1763:15, 1768:40,

1771:31, 1772:31,

1778:36, 1779:6,

1779:9, 1785:42,

1786:45, 1794:30,

1798:8, 1800:6,

1800:26

provided [16] -

1703:6, 1708:47,

1722:1, 1729:5,

1735:38, 1735:40,

1735:45, 1736:44,

1743:25, 1746:45,

1748:34, 1757:27,

1762:6, 1762:39,

1775:19, 1776:35

provider [1] - 1754:34

providers [4] -

1703:23, 1758:15,

1761:16, 1788:41

provides [3] -

1742:38, 1779:2,

1780:2

providing [16] -

1699:26, 1702:28,

1720:32, 1722:19,

1723:6, 1725:9,

1733:1, 1736:3,

1736:4, 1738:4,

1748:36, 1763:26,

1763:27, 1774:38,

1789:3, 1790:8

provision [4] -

1698:26, 1703:7,

1733:19, 1787:19

provisioning [1] -

1761:35

Psychiatric [3] -

1737:45, 1738:19,

1738:23

Psychiatrist [6] -

1748:25, 1758:11,

1758:37, 1771:15,

1788:30, 1788:33

psychiatry [1] -

1749:38

psychogeriatric [1] -

1715:3

psychological [1] -

1759:12

psychosocial [2] -

1739:17, 1790:20

psychotic [1] -

1798:41

psychotically [1] -

1754:7

public [33] - 1697:25,

1697:40, 1697:44,

1698:29, 1700:18,

1702:11, 1709:21,

1709:27, 1710:27,

1710:43, 1712:5,

1712:11, 1713:46,

1714:14, 1714:36,

1727:10, 1728:36,

1739:2, 1739:27,

1756:1, 1757:21,

1762:22, 1764:14,

1764:21, 1768:6,

1770:11, 1771:29,

1773:6, 1778:10,

1782:47, 1787:6,

1797:46, 1800:13

Public [4] - 1698:9,

1698:10, 1713:36,

1756:21

publicised [1] -

1739:24

publicly [2] - 1769:27,

1781:4

published [5] -

1698:32, 1698:35,

1698:36, 1705:41,

1747:34

pull [1] - 1765:37

purchase [3] -

1743:18, 1743:19

purchaser/provider

[1] - 1761:11

purchasing [1] -

1743:16

purpose [7] - 1734:26,

1734:29, 1763:6,

1763:26, 1783:32,

1784:45, 1797:16

purpose-built [2] -

1734:26, 1734:29

purposeful [1] -

1725:20

purposes [3] -

1708:24, 1764:2,

1776:9

pursue [1] - 1787:9

pursuing [1] - 1722:35

put [29] - 1703:34,

1712:24, 1712:38,

1724:37, 1724:47,

1725:2, 1726:24,

1726:34, 1726:38,

1728:32, 1739:40,

1741:2, 1742:8,

1742:12, 1744:47,

1750:1, 1751:34,

1757:13, 1764:3,

1765:16, 1769:23,

1771:45, 1774:39,

1775:14, 1777:20,

1780:34, 1786:2,

1786:24, 1800:18

putting [4] - 1741:46,

1757:31, 1777:35,

1787:36

puzzle [1] - 1770:25

Q

QC [1] - 1696:34

qualifications [2] -

1713:23, 1737:6

qualified [2] -

1725:32, 1726:45

qualitative [1] -

1779:30

quality [30] - 1706:37,

1706:46, 1707:1,

1709:1, 1715:27,

1716:27, 1718:46,

1720:32, 1725:46,

1727:42, 1728:6,

1733:20, 1734:45,

1735:4, 1735:15,

1735:17, 1735:27,

1736:17, 1740:43,

1740:44, 1747:19,

1748:45, 1751:43,

1771:31, 1775:17,

1780:21, 1788:8,

1788:26, 1790:42,

1791:12

quality) [1] - 1762:22

quantity [1] - 1706:36

quantum [2] -

1700:27, 1724:8

quarterly [3] - 1728:2,

1782:1, 1793:16

Queensland [1] -

1697:12

questioning [2] -

1698:27, 1698:29

questions [18] -

1703:33, 1710:20,

1714:33, 1717:28,

1719:42, 1734:14,

1735:47, 1744:42,

1752:19, 1756:29,

1764:2, 1764:13,

1764:32, 1779:23,

1783:12, 1794:12,

1798:20, 1801:30

quick [2] - 1773:1,

1773:10

quickly [6] - 1730:11,

1750:29, 1773:39,

1781:44, 1786:20,

1795:12

quite [26] - 1702:38,

1704:22, 1707:46,

1714:18, 1720:18,

1720:27, 1720:30,

1724:38, 1725:12,

1727:28, 1731:32,

1735:40, 1736:7,

1736:9, 1743:15,

1747:33, 1748:17,

1750:17, 1759:37,

1763:3, 1776:43,

1790:9, 1794:19,

1800:3, 1800:26,

1801:21

quits [1] - 1784:11

R

radiology [2] -

1743:18, 1743:21

raise [3] - 1734:40,

1788:18, 1790:47

raised [7] - 1702:6,

1712:44, 1725:38,

1732:2, 1746:8,

1750:38, 1791:20

range [12] - 1706:4,

1729:46, 1735:37,

1747:30, 1769:24,

1769:26, 1769:42,

1780:3, 1780:4,

1783:19, 1783:22,

1797:38

rapid [3] - 1757:17,

1764:39, 1770:20

rate [7] - 1707:45,

1708:16, 1752:36,

1752:37, 1771:34,

1798:13

rates [5] - 1744:36,

1776:25, 1776:27,

1776:28

rather [6] - 1708:2,

1749:47, 1769:18,

1787:38, 1792:11,

1794:28

rationale [2] -

1787:27, 1794:36

rationalisation [1] -

1707:9

re [2] - 1744:36,

1787:23

re-admission [1] -

1744:36

re-integrating [1] -

1787:23

reach [1] - 1699:26

read [7] - 1705:6,

1708:27, 1709:23,

1711:37, 1728:31,

1766:38, 1789:21

readily [1] - 1719:40

readmissions [1] -

1757:33

reads [1] - 1768:36

ready [1] - 1793:37

real [5] - 1739:23,

1741:17, 1742:3,

1780:46, 1804:2

realise [2] - 1751:38,

1771:24

realised [3] - 1756:42,

1758:44, 1768:26

realistic [5] - 1712:17,

1712:20, 1763:12,

1774:36, 1802:14

reality [1] - 1769:41

really [96] - 1704:23,

1705:26, 1707:6,

1708:7, 1708:19,

1710:14, 1710:41,

1711:3, 1712:21,

1715:37, 1715:46,

1716:5, 1716:43,

1723:3, 1723:41,

1727:39, 1729:23,

1729:34, 1731:24,

1733:45, 1735:46,

1738:38, 1740:23,

1747:38, 1749:30,

1749:47, 1751:7,

1757:2, 1757:8,

1760:15, 1761:6,

1761:9, 1762:35,

.25/07/2019 (18)


26

1763:3, 1763:21,

1763:22, 1763:23,

1763:27, 1763:39,

1765:37, 1769:5,

1771:41, 1772:27,

1772:36, 1772:47,

1773:16, 1773:46,

1774:2, 1774:17,

1774:19, 1774:20,

1774:36, 1775:15,

1776:30, 1778:29,

1778:30, 1779:41,

1780:1, 1780:19,

1780:20, 1781:17,

1781:31, 1782:8,

1782:18, 1783:36,

1784:45, 1785:7,

1785:18, 1785:33,

1786:2, 1786:7,

1786:32, 1787:6,

1787:22, 1788:30,

1788:34, 1789:15,

1789:31, 1790:33,

1795:15, 1795:24,

1795:37, 1796:31,

1796:41, 1798:2,

1798:4, 1798:16,

1799:2, 1800:22,

1801:16, 1802:16,

1802:41, 1802:43,

1802:45, 1803:13,

1803:26

reason [9] - 1701:39,

1707:23, 1710:6,

1710:13, 1749:21,

1774:45, 1793:45,

1795:7, 1795:13

reasonably [3] -

1766:5, 1769:11,

1773:1

reasons [3] - 1772:23,

1797:7, 1801:2

reassurance [1] -

1722:19

receive [14] - 1700:4,

1701:17, 1717:18,

1722:32, 1722:33,

1725:11, 1725:47,

1726:2, 1749:14,

1749:28, 1750:9,

1751:41, 1758:17,

1770:9

received [9] - 1700:45,

1724:32, 1731:1,

1731:25, 1739:32,

1739:44, 1776:27,

1782:6, 1782:16

receiving [3] - 1723:7,

1732:30, 1743:47

recent [6] - 1709:8,

1710:45, 1727:12,

1730:45, 1776:33,

1786:23

recently [12] -

1697:21, 1698:32,

1702:10, 1705:39,

1705:45, 1707:28,

1711:38, 1712:44,

1744:24, 1758:11,

1767:40, 1767:41

receptive [1] -

1740:46

recognise [1] - 1767:8

recognised [1] -

1722:38

recognising [2] -

1764:14, 1771:6

recognition [1] -

1798:5

recommendation [1] -

1712:8

recommendations

[10] - 1701:24,

1711:40, 1711:44,

1712:1, 1712:2,

1712:9, 1748:24,

1779:6, 1784:29,

1800:46

recommended [1] -

1786:4

reconsider [1] -

1715:21

record [2] - 1754:26,

1754:31

records [1] - 1743:47

recovery [5] -

1756:40, 1759:13,

1759:15, 1771:4,

1786:11

recovery-oriented [2]

- 1756:40, 1771:4

recruit [8] - 1725:13,

1725:29, 1726:4,

1726:37, 1726:44,

1727:2, 1729:16,

1731:7

recruiting [1] -

1726:41

rectification [1] -

1748:23

Red [1] - 1737:31

redevelopment [1] -

1731:43

redress [1] - 1747:14

reduce [2] - 1709:44,

1763:7

reduced [1] - 1781:8

reducing [2] -

1706:15, 1746:43

reduction [1] -

1708:15

reductions [1] -

1768:47

refer [3] - 1699:1,

1706:42, 1723:18

reference [5] - 1706:2,

1708:12, 1761:29,

1770:47, 1777:15

referenced [1] -

1765:12

references [1] -

1770:30

referral [2] - 1768:3,

1793:9

referred [6] - 1702:10,

1703:35, 1705:17,

1708:16, 1769:31,

1801:19

referring [3] - 1732:5,

1746:13, 1796:1

reflect [8] - 1699:19,

1708:31, 1763:23,

1764:37, 1772:35,

1778:45, 1782:25,

1791:21

reflected [3] -

1740:27, 1771:10,

1777:36

reflecting [1] -

1779:35

reflection [2] - 1773:9,

1799:37

reflections [4] -

1763:17, 1772:28,

1782:14, 1782:34

reform [30] - 1699:36,

1700:26, 1709:41,

1740:9, 1740:24,

1741:6, 1741:35,

1751:13, 1751:14,

1756:36, 1761:2,

1767:46, 1770:31,

1778:38, 1780:17,

1781:10, 1781:15,

1783:4, 1784:47,

1785:14, 1785:16,

1797:33, 1799:17,

1799:21, 1799:29,

1799:33, 1799:38,

1799:40, 1800:15,

1800:27

reforms [5] - 1732:12,

1739:34, 1740:32,

1740:47, 1749:12

refugee [1] - 1789:19

regarding [2] -

1717:36, 1735:28

regardless [1] -

1732:38

regional [2] - 1767:4,

1777:35

regular [6] - 1722:30,

1727:15, 1735:20,

1735:24, 1735:25,

1745:6

regularly [1] - 1735:1

regulated [1] - 1767:1

regulation [1] -

1750:12

regulations [1] -

1698:2

rehab [1] - 1739:17

rehabilitation [1] -

1786:12

reinforce [2] -

1771:20, 1800:12

reintegrated [1] -

1796:25

reiterate [2] - 1772:10,

1796:43

reject [1] - 1749:32

relapse [1] - 1759:15

relate [6] - 1701:32,

1701:41, 1703:3,

1744:16, 1791:1,

1792:24

related [5] - 1704:41,

1711:11, 1717:32,

1757:44, 1770:35

relation [29] - 1698:9,

1698:33, 1701:43,

1703:38, 1704:31,

1705:37, 1707:44,

1711:38, 1714:36,

1717:4, 1717:7,

1723:14, 1729:38,

1738:5, 1747:20,

1754:29, 1754:30,

1755:17, 1781:43,

1782:15, 1782:44,

1784:23, 1795:3,

1796:28, 1798:9,

1798:41, 1798:43,

1799:16, 1802:24

relationship [7] -

1698:4, 1698:8,

1698:14, 1761:12,

1785:29, 1785:32,

1803:30

relationships [1] -

1783:24

relative [1] - 1797:21

relatively [1] - 1767:41

released [5] - 1739:38,

1769:24, 1769:27,

1777:33, 1778:42

relevant [4] - 1742:8,

1742:24, 1784:39,

1793:7

reliability [1] -

1697:43

reliant [1] - 1744:4

relies [1] - 1731:19

relocating [1] - 1739:3

reluctance [1] -

1707:19

rely [1] - 1719:43

remain [3] - 1726:28,

1757:38, 1771:36

remained [1] -

1792:34

remains [1] - 1770:42

removes [1] - 1749:26

renew [1] - 1767:29

rent [2] - 1734:25,

1734:26

rental [1] - 1734:33

repeat [1] - 1710:37

repeating [1] -

1764:24

report [22] - 1697:43,

1698:29, 1701:24,

1701:40, 1702:10,

1705:17, 1705:25,

1708:16, 1711:8,

1712:4, 1722:4,

1729:35, 1735:5,

1735:19, 1735:27,

1740:36, 1765:6,

1766:42, 1779:45,

1780:25, 1790:41,

1800:43

Report [10] - 1698:40,

1698:42, 1700:34,

1765:2, 1765:18,

1769:32, 1772:1,

1781:3, 1781:25,

1784:23

report's [1] - 1712:44

reported [11] -

1697:44, 1718:47,

1722:12, 1729:36,

1735:23, 1738:27,

1781:4, 1781:42,

1782:32, 1795:22,

1795:23

reporting [17] -

1718:29, 1722:34,

1723:29, 1725:16,

1735:20, 1735:26,

1736:7, 1736:21,

1742:17, 1750:20,

1781:47, 1782:1,

1782:2, 1782:4,

1782:23, 1782:40

reports [15] - 1698:33,

1701:40, 1701:42,

1702:4, 1702:6,

1702:9, 1703:5,

1711:38, 1711:39,

.25/07/2019 (18)


27

1712:14, 1720:2,

1720:6, 1739:37,

1800:45

representation [1] -

1794:26

representative [1] -

1728:14

represented [1] -

1794:44

request [1] - 1697:31

requested [1] -

1728:12

require [4] - 1698:44,

1701:10, 1707:40,

1759:45

required [14] -

1700:28, 1707:9,

1725:45, 1728:27,

1746:39, 1747:1,

1756:36, 1758:45,

1759:9, 1778:11,

1793:30, 1795:21,

1795:34, 1795:35

requirement [2] -

1750:11, 1774:42

requirements [1] -

1720:32

requires [1] - 1760:44

requiring [1] -

1716:29

RES.0002.0005.0001

[1] - 1759:25

Research [1] -

1737:19

research [1] - 1803:24

reside [1] - 1796:45

residential [4] -

1715:5, 1732:46,

1735:39, 1739:13

resides [1] - 1798:36

residing [1] - 1726:44

resigned [1] - 1715:21

resolved [1] - 1788:22

resource [1] - 1798:16

resourced [1] -

1712:46

Resources [1] -

1756:12

resources [10] -

1709:25, 1711:18,

1712:32, 1729:15,

1746:19, 1757:26,

1759:8, 1759:11,

1772:24, 1783:10

Resourcing [1] -

1762:2

resourcing [7] -

1762:8, 1764:32,

1772:21, 1790:38,

1791:26, 1801:5,

1801:24

respect [2] - 1782:45,

1792:17

respiratory [1] -

1790:43

respond [7] - 1701:21,

1739:41, 1740:18,

1740:19, 1764:38,

1766:34, 1767:33

responding [1] -

1785:2

response [7] -

1701:10, 1702:7,

1702:12, 1706:21,

1758:14, 1790:26,

1802:31

responsibilities [7] -

1720:12, 1720:15,

1738:22, 1761:32,

1787:24, 1787:25,

1791:5

responsibility [12] -

1703:27, 1704:29,

1711:17, 1725:22,

1742:43, 1743:6,

1743:45, 1749:23,

1761:15, 1765:21,

1788:7, 1790:39

responsible [15] -

1701:6, 1728:28,

1738:24, 1739:8,

1740:25, 1742:46,

1743:24, 1743:26,

1745:2, 1753:18,

1767:21, 1789:3,

1790:3, 1793:8,

1796:27

rest [3] - 1703:14,

1715:47, 1725:17

restrained [1] -

1744:25

restraint [2] - 1744:30,

1744:34

restricted [1] -

1744:19

restricts [1] - 1758:30

result [8] - 1699:20,

1708:32, 1711:26,

1725:24, 1725:32,

1725:33, 1770:38,

1780:31

resulted [2] - 1739:42,

1780:21

resulting [3] -

1746:41, 1757:32,

1758:19

results [4] - 1700:9,

1709:41, 1724:7,

1798:9

RESUMING [1] -

1736:37

resuscitation [1] -

1754:4

retrained [1] - 1744:31

retrieval [1] - 1802:35

return [5] - 1700:32,

1772:31, 1773:12,

1773:14, 1788:3

returns [1] - 1773:1

revenue [1] - 1728:41

review [10] - 1699:37,

1722:16, 1722:36,

1739:28, 1749:39,

1775:17, 1790:41,

1791:10, 1791:30,

1791:47

Review [2] - 1701:44,

1741:37

reviewing [2] -

1716:21, 1722:13

reviews [7] - 1699:33,

1702:6, 1722:6,

1748:21, 1748:24,

1748:25, 1748:26

rhythm [1] - 1785:10

rich [2] - 1765:33,

1765:39

richer [1] - 1765:39

rights [2] - 1740:43,

1756:40

rights-based [1] -

1756:40

ringfence [2] -

1724:38, 1725:7

rise [2] - 1700:12,

1791:13

risk [7] - 1700:12,

1700:29, 1710:7,

1763:2, 1767:33,

1780:8

risks [7] - 1709:37,

1710:1, 1710:5,

1710:16, 1745:18,

1757:46, 1779:38

Road [1] - 1780:44

roadmap [1] - 1779:7

rob [1] - 1703:24

robust [6] - 1736:9,

1736:11, 1747:33,

1780:29, 1796:19,

1800:2

role [47] - 1697:36,

1697:38, 1697:41,

1701:32, 1701:37,

1701:45, 1702:12,

1702:14, 1704:13,

1704:24, 1709:17,

1709:20, 1709:21,

1711:43, 1714:10,

1714:15, 1714:21,

1714:29, 1720:36,

1737:11, 1737:41,

1738:7, 1738:22,

1738:25, 1738:29,

1742:36, 1755:44,

1755:47, 1760:33,

1760:36, 1760:37,

1760:40, 1760:47,

1761:6, 1761:15,

1762:28, 1763:24,

1763:42, 1766:45,

1766:47, 1785:24,

1789:8, 1789:44,

1791:37, 1796:28,

1803:26, 1803:46

role" [1] - 1702:13

roles [9] - 1697:15,

1714:3, 1714:9,

1720:12, 1734:5,

1737:40, 1738:5,

1744:44, 1756:1

roll [1] - 1793:42

rolled [4] - 1767:41,

1783:17, 1783:20,

1789:24

Room [1] - 1696:11

root [3] - 1701:28,

1701:31, 1749:2

Rosebud [3] -

1726:44, 1726:46,

1727:4

Roundtable [1] -

1747:44

routine [1] - 1782:22

routinely [4] -

1744:19, 1747:41,

1750:17, 1773:38

ROYAL [1] - 1696:5

Royal [17] - 1697:30,

1712:10, 1719:19,

1741:45, 1757:2,

1757:7, 1757:9,

1779:4, 1779:6,

1781:30, 1784:41,

1784:42, 1790:7,

1794:13, 1795:40,

1799:5, 1801:25

rule [1] - 1749:46

run [13] - 1717:15,

1724:13, 1726:4,

1727:29, 1738:26,

1739:1, 1739:2,

1739:4, 1739:17,

1742:40, 1744:38,

1759:33, 1759:43

running [6] - 1724:42,

1732:45, 1732:47,

1738:29, 1753:18,

1800:38

S

sad [1] - 1747:7

sadly [1] - 1795:12

safe [6] - 1720:32,

1722:19, 1725:46,

1726:23, 1740:2,

1785:43

safeguard [1] -

1794:24

safely [1] - 1730:20

Safer [3] - 1788:30,

1788:35, 1802:32

safety [11] - 1718:46,

1727:42, 1728:6,

1749:30, 1749:47,

1775:17, 1780:21,

1788:8, 1790:41,

1791:12, 1802:47

Safety [1] - 1780:44

salaries [1] - 1746:33

salary [3] - 1746:34,

1746:41

sat [1] - 1741:11

satisfactory [1] -

1764:23

savings [3] - 1724:17,

1746:39, 1747:1

saw [3] - 1745:7,

1796:19, 1800:42

scale [2] - 1801:43,

1803:27

scaling [1] - 1783:41

scenarios [1] - 1774:1

Science [2] - 1713:24,

1737:8

scope [4] - 1727:9,

1764:15, 1778:32,

1795:39

screen [1] - 1765:13

screens [1] - 1765:47

scrutiny [1] - 1782:41

se [1] - 1708:5

seclusion [1] -

1744:36

second [12] - 1698:35,

1701:34, 1712:23,

1759:33, 1772:34,

1773:13, 1773:41,

1779:20, 1787:44,

1788:25, 1790:42,

1791:34

second-guess [1] -

1712:23

secondly [5] -

1763:30, 1766:33,

1770:23, 1785:9,

1789:15

secondment [1] -

.25/07/2019 (18)


28

1714:19

Secretary [6] - 1707:9,

1755:40, 1756:6,

1756:10, 1756:15,

1772:35

secretary [2] -

1737:42, 1740:39

Secretary's [1] -

1711:29

section [1] - 1771:11

Section [1] - 1758:21

sector [14] - 1697:26,

1697:40, 1697:44,

1698:34, 1709:27,

1710:27, 1720:24,

1737:27, 1751:44,

1762:22, 1779:2,

1786:32, 1791:32,

1800:7

sector's [1] - 1709:21

secured [2] - 1783:23

securing [2] -

1772:24, 1802:2

see [39] - 1701:31,

1702:41, 1703:2,

1705:33, 1708:16,

1709:17, 1711:33,

1712:17, 1718:23,

1720:5, 1720:37,

1721:31, 1731:17,

1731:34, 1732:7,

1733:8, 1733:21,

1742:13, 1743:26,

1749:40, 1751:44,

1752:16, 1759:32,

1766:10, 1766:30,

1766:38, 1767:26,

1767:46, 1768:17,

1769:31, 1770:45,

1778:16, 1785:39,

1786:36, 1787:41,

1789:32, 1791:28,

1800:47

seeing [5] - 1707:5,

1723:30, 1732:32,

1748:38, 1774:28

seek [5] - 1723:23,

1729:7, 1739:9,

1758:31, 1770:8

seeking [5] - 1745:25,

1759:45, 1770:4,

1799:30, 1802:25

seeks [1] - 1770:6

seem [3] - 1702:7,

1706:19, 1728:25

senior [8] - 1721:39,

1734:43, 1735:44,

1741:33, 1755:47,

1767:21, 1782:23,

1800:20

sense [7] - 1703:21,

1703:23, 1709:10,

1712:16, 1730:5,

1750:44, 1763:26

senses [1] - 1761:6

sensitive [1] - 1700:19

sentinel [2] - 1749:1,

1780:23

separate [3] -

1698:20, 1703:12,

1779:1

separately [2] -

1785:39, 1792:43

separation [1] -

1799:1

sequencing [1] -

1785:19

series [6] - 1739:38,

1739:39, 1747:28,

1748:21, 1748:24,

1764:12

serious [6] - 1722:5,

1735:6, 1735:26,

1748:16, 1771:41,

1785:40

serve [2] - 1743:7,

1780:13

served [1] - 1742:29

serves [2] - 1742:41,

1742:42

service [160] -

1699:26, 1701:4,

1701:33, 1701:47,

1703:16, 1703:22,

1703:40, 1703:41,

1704:24, 1706:36,

1706:47, 1708:17,

1709:36, 1710:27,

1710:43, 1712:18,

1714:22, 1714:24,

1714:42, 1715:4,

1715:26, 1715:40,

1716:8, 1716:9,

1716:12, 1716:17,

1716:22, 1716:40,

1716:44, 1718:10,

1718:14, 1719:36,

1719:38, 1719:46,

1720:21, 1721:37,

1722:21, 1723:6,

1723:7, 1723:44,

1724:3, 1724:21,

1724:32, 1725:17,

1725:23, 1725:30,

1725:46, 1726:6,

1726:9, 1727:10,

1727:40, 1728:9,

1728:21, 1728:25,

1729:5, 1729:6,

1729:10, 1729:23,

1729:42, 1730:14,

1730:27, 1731:19,

1732:12, 1732:23,

1732:26, 1732:28,

1732:29, 1733:12,

1733:19, 1733:37,

1733:43, 1733:44,

1735:29, 1736:2,

1736:4, 1738:12,

1741:35, 1742:7,

1742:16, 1742:20,

1742:28, 1745:25,

1745:31, 1746:23,

1746:43, 1747:21,

1747:25, 1747:29,

1748:20, 1748:27,

1749:14, 1749:23,

1749:28, 1750:7,

1750:17, 1751:12,

1752:15, 1754:37,

1755:13, 1756:1,

1756:40, 1758:15,

1760:26, 1760:27,

1761:17, 1761:22,

1761:23, 1761:36,

1761:41, 1761:42,

1762:4, 1762:18,

1762:25, 1762:40,

1763:30, 1765:21,

1765:23, 1770:7,

1770:8, 1773:2,

1773:5, 1773:7,

1774:24, 1775:39,

1777:30, 1778:18,

1778:22, 1779:26,

1780:13, 1780:15,

1781:22, 1781:42,

1782:15, 1782:16,

1783:1, 1785:25,

1786:21, 1787:19,

1788:28, 1788:36,

1788:41, 1789:11,

1789:17, 1789:18,

1789:39, 1791:40,

1792:12, 1793:13,

1793:21, 1800:10,

1800:14, 1800:17,

1801:7, 1801:17,

1801:27, 1801:44,

1802:20, 1802:33,

1803:47

Service [1] - 1737:31

Services [13] -

1698:35, 1699:6,

1699:42, 1717:46,

1722:25, 1737:45,

1738:19, 1738:20,

1738:23, 1755:41,

1772:36, 1786:44,

1787:14

services [232] -

1698:44, 1699:8,

1699:26, 1699:44,

1700:18, 1700:21,

1700:25, 1700:28,

1700:36, 1700:38,

1700:45, 1701:3,

1701:6, 1701:7,

1702:1, 1703:3,

1703:6, 1703:7,

1703:11, 1703:17,

1703:43, 1704:3,

1704:8, 1704:26,

1704:29, 1704:36,

1704:39, 1704:47,

1705:20, 1707:36,

1707:38, 1708:44,

1712:34, 1714:14,

1714:35, 1714:36,

1714:38, 1714:44,

1714:45, 1715:1,

1715:5, 1715:6,

1715:11, 1716:21,

1718:13, 1718:14,

1719:38, 1720:13,

1720:15, 1720:18,

1720:33, 1721:11,

1721:33, 1721:40,

1722:7, 1722:32,

1722:47, 1723:4,

1723:31, 1723:32,

1724:13, 1724:41,

1724:43, 1724:47,

1725:8, 1725:9,

1725:22, 1725:35,

1725:45, 1725:47,

1726:5, 1726:11,

1726:17, 1727:14,

1728:28, 1728:37,

1728:38, 1728:43,

1729:17, 1729:19,

1729:46, 1730:6,

1730:29, 1730:47,

1731:10, 1731:17,

1731:27, 1731:34,

1732:4, 1732:18,

1732:32, 1732:42,

1733:5, 1733:15,

1733:17, 1733:22,

1733:26, 1733:29,

1734:18, 1734:19,

1734:29, 1735:7,

1735:37, 1735:40,

1735:45, 1735:47,

1736:2, 1738:25,

1738:29, 1738:30,

1738:32, 1738:40,

1739:1, 1739:4,

1739:5, 1739:10,

1739:14, 1739:17,

1740:26, 1740:33,

1740:43, 1740:44,

1741:19, 1742:4,

1742:38, 1742:41,

1742:44, 1742:47,

1743:1, 1743:7,

1743:8, 1743:12,

1743:14, 1743:17,

1743:18, 1743:19,

1743:21, 1743:24,

1743:36, 1743:41,

1744:17, 1744:21,

1744:29, 1744:38,

1744:46, 1745:3,

1745:5, 1745:8,

1745:35, 1746:24,

1747:26, 1747:30,

1747:40, 1747:46,

1749:4, 1749:28,

1749:35, 1749:44,

1750:23, 1750:28,

1751:43, 1752:4,

1754:18, 1754:41,

1756:38, 1757:18,

1757:22, 1757:25,

1757:32, 1758:30,

1758:45, 1759:7,

1760:16, 1760:19,

1760:45, 1761:37,

1762:3, 1762:20,

1762:39, 1763:32,

1763:38, 1765:37,

1766:34, 1768:3,

1768:20, 1770:11,

1770:12, 1770:26,

1770:36, 1770:42,

1771:3, 1771:7,

1771:30, 1771:31,

1772:6, 1772:25,

1774:23, 1778:10,

1778:31, 1781:40,

1781:41, 1784:18,

1785:36, 1786:37,

1789:5, 1790:2,

1790:4, 1791:31,

1792:19, 1793:7,

1793:9, 1793:17,

1794:2, 1796:18,

1801:20, 1801:40,

1801:41, 1801:42,

1802:35, 1802:45,

1802:46, 1803:16

set [13] - 1698:7,

1698:16, 1709:43,

1710:6, 1710:13,

1717:14, 1718:1,

1726:8, 1729:38,

1749:11, 1768:41,

1780:32, 1783:9

sets [3] - 1702:23,

1777:22

setting [7] - 1710:6,

1710:11, 1710:14,

.25/07/2019 (18)


29

1710:17, 1739:22,

1755:8, 1763:36

settings [6] - 1735:39,

1760:14, 1763:34,

1763:36, 1786:8

seven [4] - 1707:22,

1737:31, 1737:33,

1792:21

severe [3] - 1700:39,

1759:35, 1798:40

severely [3] - 1754:5,

1758:16, 1786:10

severity [2] - 1758:19,

1768:23

sexy [1] - 1747:10

shadow [1] - 1796:40

shadowed [1] -

1796:17

shadowing [1] -

1796:22

shamelessly [1] -

1719:26

shared [1] - 1803:35

sharing [1] - 1788:20

sheer [1] - 1764:42

sheet [1] - 1703:45

shift [3] - 1756:39,

1766:14, 1790:38

shifted [1] - 1797:22

shifts [1] - 1760:18

shocked [1] - 1727:28

shootings [4] -

1739:24, 1739:39,

1739:42, 1740:35

SHORT [1] - 1755:33

short [4] - 1711:41,

1739:37, 1753:29,

1782:47

shortage [1] - 1785:40

shortcomings [1] -

1700:7

shorter [1] - 1757:29

shortfall [2] - 1728:40,

1728:43

shortly [2] - 1700:32,

1778:6

shortness [1] -

1795:33

shoulders [1] -

1741:11

show [2] - 1707:22,

1772:47

showed [1] - 1748:21

shower [1] - 1730:18

showing [1] - 1794:39

shown [1] - 1765:10

side [1] - 1792:32

sight [2] - 1730:7,

1730:30

signed [1] - 1777:37

significant [35] -

1699:42, 1700:12,

1701:10, 1701:16,

1714:20, 1715:25,

1725:30, 1738:39,

1739:11, 1739:28,

1739:31, 1740:32,

1741:3, 1750:19,

1752:41, 1757:38,

1761:15, 1767:13,

1768:14, 1770:37,

1771:16, 1772:45,

1773:4, 1778:17,

1779:8, 1779:19,

1783:10, 1783:18,

1784:40, 1786:3,

1786:12, 1790:38,

1797:44, 1800:27,

1803:38

signs [1] - 1718:21

silo [1] - 1762:41

similar [9] - 1722:46,

1723:35, 1732:37,

1732:40, 1732:41,

1735:27, 1740:11,

1740:15, 1797:11

similarly [2] - 1794:21,

1797:14

simply [8] - 1704:22,

1710:5, 1743:16,

1761:11, 1763:33,

1774:47, 1791:39,

1795:41

simulation [2] -

1774:2, 1774:9

sit [3] - 1703:29,

1703:34, 1704:12

site [1] - 1753:17

sites [1] - 1743:43

sitting [4] - 1728:22,

1728:24, 1733:29,

1745:24

situation [2] -

1795:15, 1795:38

situations [3] -

1739:40, 1740:6,

1780:14

six [2] - 1754:43,

1802:40

six-month-old [1] -

1802:40

Sixth [1] - 1803:37

size [2] - 1701:19,

1789:21

skill [1] - 1782:27

Skills [1] - 1756:6

skills [1] - 1783:3

slide [2] - 1759:24,

1760:6

slightly [4] - 1777:40,

1779:42, 1789:37,

1792:35

slow [1] - 1699:35

slower [1] - 1759:15

small [1] - 1744:15

so-called [1] -

1747:10

social [7] - 1739:22,

1760:43, 1766:17,

1769:3, 1772:25,

1772:31, 1798:27

Solicitor's [2] -

1766:42, 1795:47

solutions [4] -

1774:38, 1778:25,

1778:39, 1791:42

solve [2] - 1791:44,

1795:43

solved [1] - 1791:39

someone [4] -

1749:18, 1753:1,

1753:4, 1785:16

sometimes [4] -

1707:21, 1725:12,

1748:25, 1748:26

somewhat [5] -

1719:27, 1727:38,

1751:23, 1764:3,

1789:29

sooner [1] - 1757:27

SOP [1] - 1718:29

sophisticated [2] -

1736:8, 1773:47

sophistication [1] -

1772:29

sore [1] - 1735:13

sorry [12] - 1740:12,

1746:15, 1764:24,

1766:43, 1767:43,

1773:24, 1775:15,

1777:25, 1780:41,

1792:8, 1792:38,

1792:39

sort [26] - 1735:19,

1736:10, 1741:47,

1744:36, 1748:6,

1748:47, 1751:8,

1751:42, 1754:38,

1761:21, 1776:14,

1779:2, 1782:4,

1782:28, 1783:37,

1783:39, 1789:21,

1790:20, 1792:46,

1794:31, 1797:15,

1800:16, 1800:18,

1801:24, 1802:13,

1802:14

sorts [4] - 1701:28,

1745:18, 1765:31,

1798:7

sounds [1] - 1797:32

source [2] - 1728:41,

1765:39

sources [4] - 1746:22,

1746:25, 1746:27,

1775:43

South [2] - 1737:21,

1755:1

space [13] - 1702:2,

1709:7, 1731:35,

1734:26, 1763:3,

1784:5, 1785:37,

1786:38, 1788:21,

1790:10, 1790:22,

1790:23, 1790:24

speaking [1] -

1786:28

special [1] - 1742:22

specialist [4] - 1701:2,

1715:5, 1771:29,

1788:9

specialty [2] -

1787:28, 1799:2

specific [13] -

1707:47, 1718:4,

1718:7, 1724:40,

1731:2, 1731:6,

1742:22, 1745:9,

1779:10, 1792:19,

1792:25, 1799:45,

1803:10

specifically [11] -

1703:2, 1729:35,

1734:33, 1738:18,

1745:30, 1754:2,

1754:30, 1771:10,

1792:21, 1796:1,

1802:24

specification [1] -

1762:4

specifications [1] -

1762:21

specifics [1] - 1793:23

specified [2] -

1705:10, 1725:11

spectrum [9] -

1759:44, 1766:35,

1766:39, 1766:40,

1767:10, 1767:14,

1768:4, 1768:23,

1796:31

speculate [1] -

1712:26

speech [2] - 1741:6,

1741:7

spend [5] - 1702:40,

1711:11, 1714:34,

1715:37, 1720:10

spending [1] -

1794:27

spent [2] - 1715:44,

1736:1

spread [1] - 1781:46

square [1] - 1714:40

stabilised [1] - 1753:8

stability [2] - 1796:39,

1800:16

stable [2] - 1757:40,

1800:13

Staff [1] - 1737:20

staff [27] - 1700:27,

1715:38, 1716:28,

1720:29, 1721:14,

1721:23, 1724:24,

1724:25, 1725:13,

1725:32, 1726:12,

1726:23, 1730:10,

1731:45, 1731:47,

1733:6, 1743:8,

1750:16, 1753:7,

1753:34, 1755:4,

1757:5, 1761:14,

1776:32, 1783:22,

1785:37, 1802:4

staffing [12] - 1712:30,

1716:27, 1721:14,

1721:20, 1723:47,

1724:42, 1725:37,

1726:8, 1726:21,

1726:24, 1727:41,

1731:45

stage [3] - 1722:34,

1767:39, 1772:19

stages [2] - 1758:47,

1797:14

staging [1] - 1799:21

stand [2] - 1741:14,

1787:38

stand-alone [1] -

1787:38

standard [3] -

1732:31, 1782:40,

1802:36

stands [1] - 1702:15

staph [1] - 1735:5

start [10] - 1710:22,

1724:18, 1732:18,

1738:7, 1742:36,

1751:42, 1756:29,

1778:5, 1786:1,

1795:17

start/stop [1] -

1777:14

started [7] - 1713:43,

1724:11, 1738:13,

1751:20, 1777:13,

1797:24, 1799:34

starting [4] - 1724:14,

1724:16, 1724:19,

1803:38

.25/07/2019 (18)


30

state [16] - 1697:26,

1732:46, 1738:24,

1738:26, 1756:30,

1763:40, 1764:42,

1766:45, 1767:21,

1768:14, 1770:21,

1771:40, 1784:15,

1801:42, 1802:36,

1803:30

State [10] - 1737:37,

1746:16, 1746:19,

1747:34, 1751:32,

1752:11, 1752:14,

1752:31, 1752:34,

1752:35

Statement [39] -

1717:2, 1717:5,

1717:7, 1717:10,

1717:19, 1717:21,

1717:24, 1717:26,

1717:29, 1717:36,

1717:41, 1717:47,

1718:2, 1718:4,

1718:8, 1718:15,

1718:17, 1718:20,

1718:23, 1718:26,

1718:29, 1719:12,

1719:14, 1720:2,

1722:3, 1723:42,

1728:7, 1734:41,

1782:1, 1792:20,

1792:22, 1792:26,

1792:30, 1792:36,

1792:38, 1793:14,

1793:25, 1793:27,

1793:43

statement [60] -

1697:30, 1697:34,

1698:37, 1699:3,

1701:26, 1704:32,

1706:43, 1713:6,

1713:16, 1713:19,

1714:13, 1715:9,

1718:27, 1719:32,

1721:42, 1723:18,

1725:40, 1728:20,

1728:33, 1730:35,

1731:13, 1732:13,

1734:40, 1735:36,

1736:45, 1737:1,

1738:8, 1741:2,

1741:30, 1747:4,

1747:12, 1755:24,

1756:25, 1756:28,

1756:32, 1757:13,

1759:37, 1760:9,

1760:35, 1760:39,

1761:29, 1765:13,

1778:4, 1778:8,

1779:24, 1779:27,

1781:28, 1783:9,

1787:14, 1788:45,

1789:10, 1790:37,

1790:47, 1791:20,

1792:16, 1798:23,

1799:18, 1800:2,

1800:25, 1804:8

statements [3] -

1706:47, 1717:38,

1775:28

Statements [3] -

1792:6, 1792:17,

1793:3

statewide [4] -

1732:17, 1732:19,

1754:32, 1775:37

static [1] - 1792:42

statistical [1] -

1773:42

status [2] - 1803:1,

1803:2

stay [6] - 1721:13,

1724:1, 1744:8,

1753:29, 1757:36,

1757:38

stays [2] - 1724:35,

1757:29

stem [1] - 1706:33

step [1] - 1750:14

stepped [8] - 1766:26,

1778:11, 1780:4,

1780:34, 1781:19,

1786:14, 1795:41,

1803:41

Steps [1] - 1767:30

steps [1] - 1791:23

steward [2] - 1701:46,

1766:47

stewardship [10] -

1760:40, 1760:45,

1761:10, 1787:24,

1789:34, 1791:5,

1791:24, 1791:37,

1792:7, 1792:9

stick [3] - 1721:29,

1725:5, 1799:17

sticking [1] - 1725:38

stigma [6] - 1773:4,

1780:10, 1787:31,

1798:39, 1798:43,

1799:8

still [22] - 1708:43,

1711:28, 1711:33,

1742:8, 1742:12,

1742:14, 1742:23,

1742:24, 1743:20,

1752:5, 1767:2,

1767:13, 1769:11,

1769:20, 1769:25,

1788:42, 1792:1,

1792:3, 1793:9,

1798:39, 1798:47

stop [1] - 1749:29

stories [1] - 1757:8

storm [1] - 1790:44

story [1] - 1705:26

straightforward [1] -

1780:31

strains [1] - 1801:39

strategic [32] - 1701:5,

1705:45, 1709:8,

1709:10, 1717:2,

1717:13, 1717:14,

1717:16, 1717:17,

1718:12, 1718:36,

1718:43, 1719:4,

1719:8, 1719:9,

1719:10, 1777:9,

1777:11, 1777:14,

1777:18, 1777:22,

1777:28, 1777:46,

1778:2, 1778:45,

1789:47, 1790:1,

1790:14, 1790:32,

1791:31, 1793:2,

1803:18

strategies [4] -

1709:9, 1739:9,

1739:47, 1740:4

strategy [10] -

1702:23, 1702:25,

1705:28, 1705:36,

1706:14, 1710:15,

1712:33, 1717:22,

1768:11, 1777:16

Strategy [1] - 1756:10

Street [1] - 1696:12

strengthen [2] -

1767:32, 1791:6

strengthening [2] -

1770:42, 1791:4

strengths [1] -

1788:31

stress [2] - 1752:5

stroke [1] - 1802:34

strong [10] - 1747:13,

1763:34, 1772:44,

1777:17, 1786:7,

1798:4, 1799:42,

1800:13, 1800:21,

1802:39

stronger [2] - 1765:36,

1801:13

strongly [1] - 1741:40

structural [2] -

1716:14, 1784:46

structure [3] -

1738:28, 1750:19,

1800:29

structures [3] -

1782:31, 1800:20,

1801:27

struggling [1] -

1708:28

sub [4] - 1748:22,

1757:41, 1777:30,

1782:33

sub-acute [1] -

1757:41

sub-committee [2] -

1748:22, 1782:33

sub-plans [1] -

1777:30

subacute [4] -

1720:21, 1739:12,

1748:47, 1754:18

subgroups [1] -

1768:22

subject [4] - 1700:18,

1788:3, 1795:5,

1797:46

subjects [1] - 1772:15

submission [7] -

1710:23, 1752:29,

1766:28, 1767:8,

1781:29, 1786:5,

1788:4

submissions [15] -

1745:1, 1745:9,

1745:13, 1745:36,

1759:21, 1759:24,

1759:28, 1760:10,

1773:33, 1775:29,

1775:35, 1776:4,

1784:15, 1785:29,

1789:38

subsequent [3] -

1724:9, 1738:15,

1768:10

subsequently [2] -

1778:23, 1782:16

subsidisation [4] -

1724:46, 1725:4,

1725:39, 1725:41

subsidise [2] -

1725:21, 1726:27

substance [5] -

1699:10, 1701:1,

1701:2, 1769:10,

1769:17

Substantial [1] -

1756:36

substantially [1] -

1767:40

success [4] - 1707:30,

1741:27, 1741:41,

1800:39

successful [3] -

1741:38, 1751:34,

1798:1

sucked [1] - 1774:38

sucking [1] - 1775:3

suffered [1] - 1748:10

sufficient [4] -

1699:11, 1699:28,

1785:34, 1789:16

sufficiently [2] -

1701:12, 1796:19

suggest [2] - 1698:43,

1770:14

suggested [2] -

1711:24, 1781:39

suggesting [1] -

1781:24

suggestion [2] -

1774:15, 1774:45

suicidal [1] - 1767:34

suicide [9] - 1706:13,

1706:15, 1707:24,

1708:15, 1767:30,

1767:34, 1767:38,

1803:44, 1804:1

Suicide [3] - 1767:29,

1777:32, 1803:46

suitable [1] - 1757:41

suite [5] - 1705:1,

1705:12, 1778:1,

1778:13, 1781:1

summarise [4] -

1715:1, 1761:35,

1775:36, 1797:33

summary [1] -

1773:27

supply [10] - 1699:7,

1699:21, 1764:10,

1764:29, 1764:32,

1772:6, 1772:11,

1772:18, 1776:9,

1782:47

Support [1] - 1739:15

support [32] -

1700:37, 1715:35,

1715:41, 1716:29,

1720:31, 1721:13,

1733:1, 1734:1,

1734:24, 1741:14,

1742:2, 1742:3,

1745:41, 1745:45,

1746:2, 1746:10,

1746:17, 1746:18,

1747:13, 1751:28,

1751:40, 1757:5,

1758:40, 1759:9,

1760:46, 1761:19,

1768:28, 1772:38,

1772:39, 1772:40,

1772:41, 1788:28

supported [10] -

1699:33, 1718:38,

1718:40, 1734:32,

1740:10, 1740:14,

.25/07/2019 (18)


31

1740:46, 1741:23,

1750:41, 1752:6

supporting [4] -

1760:25, 1765:22,

1793:2, 1793:14

supportive [1] -

1740:45

suppose [3] -

1719:22, 1726:33,

1729:8

supposed [1] -

1710:15

surge [1] - 1790:43

surgery [2] - 1745:26,

1772:38

surgical [1] - 1753:28

surplus [3] - 1725:14,

1725:18, 1725:33

surprised [5] -

1727:28, 1727:38,

1727:43, 1731:33,

1732:8

surveys [1] - 1768:44

sustainability [1] -

1799:40

Swanston [1] -

1696:12

sworn [1] - 1697:5

symptomatic [1] -

1701:27

symptoms [2] -

1758:20, 1759:16

synch [1] - 1785:10

system [152] -

1699:12, 1699:20,

1700:8, 1700:13,

1701:4, 1701:8,

1701:10, 1701:13,

1701:47, 1702:16,

1702:24, 1702:30,

1702:31, 1702:38,

1702:39, 1702:47,

1703:3, 1703:4,

1703:9, 1703:26,

1703:29, 1704:11,

1704:12, 1704:23,

1705:11, 1709:42,

1712:15, 1713:47,

1714:14, 1714:17,

1715:20, 1715:46,

1716:24, 1720:44,

1730:29, 1731:29,

1733:9, 1733:10,

1733:11, 1738:6,

1738:24, 1742:7,

1742:14, 1742:16,

1742:17, 1742:27,

1742:28, 1742:31,

1745:22, 1749:18,

1751:12, 1751:24,

1751:46, 1752:1,

1752:3, 1752:9,

1754:24, 1754:29,

1754:32, 1754:34,

1754:38, 1754:39,

1755:13, 1755:14,

1756:31, 1757:3,

1758:1, 1758:5,

1758:8, 1759:23,

1760:4, 1760:11,

1760:13, 1760:17,

1760:22, 1760:26,

1760:27, 1760:36,

1763:23, 1763:36,

1763:42, 1763:44,

1764:11, 1764:29,

1764:38, 1765:20,

1765:22, 1765:25,

1765:31, 1766:46,

1767:9, 1767:23,

1769:15, 1771:17,

1771:19, 1772:22,

1774:33, 1774:42,

1775:18, 1775:31,

1775:33, 1777:20,

1777:42, 1778:44,

1779:37, 1779:43,

1780:3, 1780:4,

1780:16, 1780:17,

1780:21, 1781:19,

1781:21, 1782:8,

1782:27, 1783:27,

1784:7, 1785:7,

1785:16, 1785:25,

1786:33, 1787:29,

1788:3, 1788:9,

1788:32, 1788:34,

1788:38, 1790:39,

1791:36, 1791:39,

1792:8, 1792:27,

1793:12, 1793:15,

1794:31, 1794:41,

1795:13, 1795:18,

1795:38, 1798:6,

1798:18, 1798:29,

1800:2, 1800:19,

1801:10, 1801:17,

1801:37, 1802:44,

1803:15, 1803:42

SYSTEM [1] - 1696:5

system-wide [1] -

1785:25

systematic [8] -

1701:15, 1701:29,

1702:44, 1703:28,

1705:33, 1728:30,

1772:17, 1784:46

systemic [2] -

1781:10, 1797:7

Systems [1] - 1760:5

systems [24] -

1701:35, 1701:46,

1703:46, 1709:37,

1712:18, 1737:47,

1738:2, 1762:25,

1763:15, 1765:32,

1772:29, 1772:30,

1773:25, 1773:37,

1774:8, 1774:20,

1774:24, 1774:36,

1774:43, 1779:26,

1780:15, 1782:38,

1783:5, 1793:3

systems' [1] - 1701:20

T

tabled [3] - 1701:41,

1701:43, 1711:38

tailored [1] - 1789:17

target [22] - 1706:11,

1706:12, 1706:14,

1706:22, 1706:26,

1707:23, 1707:24,

1707:25, 1707:43,

1707:46, 1708:5,

1708:8, 1710:12,

1710:13, 1780:24,

1780:46, 1781:6,

1794:19, 1794:22,

1794:24

Target [1] - 1794:15

targeted [3] - 1783:1,

1783:2, 1798:8

targeting [1] - 1790:40

targets [38] - 1705:30,

1706:2, 1706:3,

1706:17, 1706:20,

1706:31, 1706:32,

1706:37, 1707:13,

1707:16, 1708:2,

1709:31, 1709:32,

1709:36, 1709:38,

1710:6, 1710:8,

1710:14, 1710:17,

1724:8, 1727:17,

1729:22, 1729:23,

1729:33, 1779:24,

1779:25, 1779:30,

1779:36, 1779:39,

1780:8, 1780:20,

1780:27, 1780:28,

1781:12, 1781:15,

1781:16

Task [1] - 1799:44

task [1] - 1801:47

team [10] - 1704:3,

1715:47, 1717:33,

1719:23, 1728:19,

1731:43, 1733:35,

1733:46, 1734:1,

1796:44

Team [3] - 1722:29,

1726:43, 1754:15

teams [7] - 1722:11,

1734:2, 1734:27,

1739:15, 1744:37,

1754:40

technical [8] -

1772:27, 1773:35,

1774:2, 1774:29,

1774:41, 1775:44,

1796:11, 1797:23

technically [1] -

1774:16

techniques [1] -

1773:47

technology [7] -

1754:24, 1754:27,

1754:29, 1754:30,

1754:35, 1774:47,

1775:1

Tehan [1] - 1741:4

tempo [1] - 1799:21

tend [1] - 1780:28

tended [1] - 1773:42

tender [4] - 1697:34,

1713:19, 1737:1,

1756:28

term [10] - 1708:18,

1711:41, 1747:6,

1747:7, 1759:13,

1775:37, 1777:28,

1778:36, 1802:20

terms [35] - 1702:14,

1703:13, 1704:12,

1704:38, 1705:8,

1709:13, 1711:43,

1712:29, 1714:12,

1717:45, 1718:26,

1725:38, 1729:32,

1729:33, 1730:39,

1741:44, 1742:32,

1746:9, 1747:22,

1751:7, 1752:25,

1754:22, 1754:23,

1754:24, 1754:26,

1754:35, 1758:12,

1758:38, 1760:12,

1786:33, 1788:25,

1788:33, 1798:32,

1799:12, 1802:29

terrific [1] - 1715:35

text [2] - 1766:38,

1767:27

THE [6] - 1710:39,

1713:8, 1736:26,

1755:26, 1804:10,

1804:14

theatres [1] - 1731:22

themselves [7] -

1702:1, 1704:19,

1730:18, 1747:40,

1748:40, 1787:39,

1802:17

therapeutic [3] -

1758:43, 1785:43,

1786:8

there'd [1] - 1739:24

therefore [8] -

1698:28, 1717:35,

1720:28, 1746:39,

1749:45, 1759:14,

1777:26, 1784:8

they've [9] - 1712:7,

1727:47, 1734:24,

1736:16, 1792:40,

1802:34, 1803:4,

1803:5

thinking [12] -

1730:23, 1744:43,

1754:23, 1766:15,

1778:25, 1785:8,

1785:19, 1797:13,

1797:37, 1799:1,

1803:13, 1803:46

thinks [2] - 1712:39,

1799:11

third [4] - 1759:33,

1767:27, 1773:22,

1778:40

thirds [2] - 1766:9,

1767:26

thoroughly [1] -

1741:13

thousands [1] -

1752:42

three [17] - 1704:2,

1706:11, 1707:21,

1714:18, 1714:22,

1730:34, 1730:36,

1731:2, 1731:9,

1731:42, 1737:29,

1742:47, 1744:18,

1772:20, 1777:17,

1786:19, 1802:14

three-month [2] -

1714:18, 1714:22

three-year [1] -

1706:11

throughout [4] -

1725:11, 1747:13,

1763:44, 1801:33

thunder [1] - 1790:44

Thursday [1] -

1696:18

tie [2] - 1706:26,

1707:44

timed [1] - 1712:45

timeframe [6] -

.25/07/2019 (18)


32

1707:18, 1712:17,

1712:20, 1712:26,

1730:42, 1802:14

timeframes [1] -

1706:10

timeliness [1] -

1747:19

timing [4] - 1785:9,

1785:14, 1793:45,

1799:26

title [1] - 1698:43

titles [1] - 1737:42

TO [1] - 1804:14

today [13] - 1704:19,

1709:32, 1713:6,

1742:24, 1752:22,

1755:24, 1758:12,

1768:31, 1792:4,

1801:33, 1803:14,

1804:8, 1804:12

today's [1] - 1775:25

together [10] -

1704:10, 1711:31,

1761:42, 1765:37,

1767:20, 1785:8,

1788:43, 1790:19,

1790:25, 1791:38

took [5] - 1719:26,

1741:6, 1741:7,

1742:43, 1777:18

tools [2] - 1781:47,

1782:38

top [6] - 1709:10,

1711:34, 1724:22,

1728:33, 1759:33,

1766:11

top-down [3] -

1709:10, 1711:34,

1724:22

topic [9] - 1730:34,

1738:34, 1744:43,

1763:47, 1776:22,

1779:12, 1787:5,

1788:2, 1789:37

Topp [4] - 1713:11,

1713:15, 1734:8,

1734:16

TOPP [1] - 1713:13

touch [1] - 1732:2

touched [3] - 1723:12,

1724:45, 1729:6

toured [1] - 1731:33

toward [1] - 1708:45

Towards [1] - 1780:46

towards [2] - 1708:33,

1719:4

town [1] - 1749:27

Town [1] - 1696:11

track [2] - 1704:36,

1710:15

traditionally [1] -

1802:7

train [2] - 1739:47,

1740:3

Training [1] - 1756:7

trajectory [1] -

1792:45

transfer [1] - 1743:30

transferred [1] -

1750:16

transition [8] -

1743:27, 1750:22,

1750:27, 1750:29,

1750:32, 1750:35,

1750:41, 1750:42

translates [1] -

1763:31

translating [1] -

1773:24

Transport [1] -

1756:11

trauma [1] - 1797:20

Treasury [4] -

1707:10, 1737:46,

1746:6, 1797:34

treat [3] - 1700:37,

1749:45, 1753:9

treated [2] - 1749:22,

1758:29

treatment [24] -

1721:13, 1739:33,

1744:1, 1744:2,

1749:15, 1753:28,

1753:30, 1757:46,

1758:3, 1758:17,

1758:28, 1758:31,

1758:40, 1758:46,

1759:9, 1759:34,

1759:35, 1759:36,

1759:43, 1759:45,

1786:11, 1798:28

Treatment [1] -

1739:15

trends [2] - 1747:29,

1767:33

triage [5] - 1700:13,

1705:20, 1754:14,

1768:14, 1782:15

trial [4] - 1783:17,

1783:20, 1783:29,

1783:40

trialling [1] - 1784:6

trials [3] - 1783:16,

1783:31, 1803:27

tried [2] - 1728:16,

1761:9

trigger [2] - 1794:29,

1794:40

true [1] - 1700:16

Trust [1] - 1737:20

trust [1] - 1773:2

try [15] - 1707:24,

1708:36, 1712:23,

1721:18, 1724:29,

1724:39, 1725:8,

1726:14, 1739:46,

1739:47, 1746:43,

1747:14, 1761:28,

1778:41, 1783:45

trying [27] - 1706:7,

1708:19, 1708:25,

1709:2, 1711:12,

1715:39, 1720:20,

1721:20, 1721:21,

1725:23, 1727:6,

1727:29, 1731:38,

1732:8, 1733:19,

1733:41, 1746:9,

1749:18, 1752:24,

1754:38, 1762:46,

1774:39, 1778:33,

1785:16, 1796:47,

1802:15

turn [5] - 1757:31,

1763:47, 1765:9,

1765:11, 1765:16

turning [1] - 1782:6

Twelve [1] - 1728:5

two [41] - 1697:41,

1698:32, 1698:37,

1701:29, 1701:31,

1702:4, 1703:4,

1704:41, 1707:8,

1712:6, 1714:14,

1720:26, 1720:27,

1720:35, 1723:32,

1728:13, 1729:16,

1731:16, 1732:13,

1739:21, 1739:25,

1739:39, 1746:41,

1762:10, 1763:17,

1763:20, 1766:9,

1767:26, 1767:42,

1770:29, 1772:22,

1776:30, 1778:38,

1780:43, 1781:44,

1785:5, 1785:32,

1786:13, 1790:37,

1792:33, 1797:18

two-thirds [2] -

1766:9, 1767:26

tying [1] - 1708:37

type [4] - 1760:25,

1773:5, 1775:20,

1782:13

types [2] - 1723:47,

1774:4

typical [1] - 1757:30

typically [3] - 1707:17,

1746:12, 1746:18

U

UK [1] - 1780:19

ultimate [2] - 1708:11,

1708:13

unable [6] - 1701:9,

1720:29, 1725:31,

1726:4, 1729:8,

1739:33

unacceptable [1] -

1795:44

unacceptably [1] -

1794:27

unanticipated [3] -

1746:22, 1746:27,

1746:28

unaware [1] - 1730:30

unbudgeted [1] -

1726:16

uncertain [2] -

1783:21

uncertainty [1] -

1701:14

unclear [1] - 1732:46

uncomfortable [1] -

1781:8

uncontrollable [1] -

1708:6

uncovered [2] -

1738:43, 1739:20

uncovering [1] -

1739:30

under [17] - 1706:46,

1728:22, 1728:24,

1742:37, 1748:1,

1752:5, 1760:39,

1766:31, 1767:46,

1768:17, 1768:34,

1769:32, 1770:31,

1793:27, 1795:18,

1798:7

under-performance

[1] - 1748:1

underfunding [1] -

1728:31

underlying [3] -

1699:19, 1757:45,

1780:9

underneath [1] -

1769:39

underscore [1] -

1799:4

underscores [1] -

1757:8

understood [7] -

1731:30, 1763:43,

1770:16, 1776:14,

1785:3, 1795:4,

1800:44

undertake [1] -

1697:41

undertaken [1] -

1779:20

undertakes [2] -

1697:42, 1697:45

undertaking [2] -

1717:30, 1783:10

undertook [3] -

1704:1, 1716:19,

1716:20

underway [1] -

1793:40

undeveloped [1] -

1773:32

unfair [1] - 1711:15

unfairness [1] -

1711:23

unfold [1] - 1799:33

unfortunate [1] -

1739:38

unfortunately [2] -

1747:7, 1753:46

unhelpful [1] - 1749:8

unintended [1] -

1743:32

unique [1] - 1701:22

unit [16] - 1715:2,

1715:3, 1716:24,

1716:32, 1721:3,

1723:46, 1724:24,

1753:29, 1753:34,

1754:1, 1754:9,

1754:41, 1796:46,

1803:1

Unit [1] - 1802:44

units [5] - 1753:20,

1753:38, 1757:29,

1757:37, 1757:39

unlike [2] - 1753:26,

1777:12

unmet [5] - 1700:16,

1700:20, 1705:23,

1729:12, 1730:25

unprecedented [1] -

1790:43

unrefined [1] -

1773:32

unregistered [1] -

1700:13

unrelated [1] -

1754:22

unresponsive [1] -

1796:2

unsatisfactory [1] -

1744:10

unusual [1] - 1752:25

unwell [4] - 1754:5,

1758:16, 1759:10,

1786:11

.25/07/2019 (18)


33

up [47] - 1704:41,

1707:38, 1707:45,

1711:14, 1711:43,

1716:30, 1717:17,

1718:47, 1720:4,

1720:7, 1722:5,

1722:7, 1722:12,

1724:21, 1724:22,

1724:30, 1725:14,

1726:47, 1727:24,

1728:41, 1730:17,

1735:28, 1742:27,

1748:39, 1749:38,

1750:1, 1751:18,

1751:31, 1752:39,

1753:29, 1755:16,

1763:4, 1763:28,

1763:36, 1765:38,

1773:24, 1773:39,

1775:3, 1776:42,

1776:43, 1780:25,

1782:32, 1785:13,

1793:45, 1799:22,

1802:23

up-front [1] - 1799:22

update [1] - 1712:1

UPON [1] - 1736:37

urgency [1] - 1777:19

urgent [2] - 1754:47,

1768:28

US [1] - 1755:3

usability [1] - 1700:8

useful [6] - 1706:30,

1706:32, 1706:33,

1730:27, 1734:41,

1781:43

V

vacancies [1] - 1727:2

vacant [1] - 1725:31

valuable [1] - 1755:13

value [4] - 1773:2,

1773:6, 1790:7,

1800:12

values [5] - 1761:1,

1763:43, 1771:9,

1786:21, 1800:15

values-based [1] -

1761:1

variability [1] -

1701:16

variables [1] - 1708:7

variation [2] -

1797:25, 1803:12

various [8] - 1697:15,

1698:1, 1720:6,

1722:1, 1743:42,

1775:28, 1788:20,

1797:35

variously [5] -

1697:46, 1701:41,

1701:46, 1702:14,

1702:33

vast [1] - 1754:44

versa [1] - 1753:35

versus [3] - 1783:32,

1783:42, 1784:37

vexed [1] - 1711:12

VGSO [1] - 1756:24

via [1] - 1746:43

vice [1] - 1753:35

vicious [2] - 1757:22,

1776:40

Victoria [30] -

1696:13, 1697:3,

1697:8, 1698:7,

1698:45, 1699:8,

1699:29, 1700:25,

1706:34, 1711:2,

1737:37, 1738:6,

1740:17, 1740:19,

1740:27, 1742:29,

1742:32, 1751:26,

1756:31, 1756:38,

1759:44, 1764:38,

1772:7, 1777:46,

1778:12, 1785:40,

1786:1, 1788:31,

1789:41, 1802:32

Victoria's [4] -

1767:30, 1767:39,

1776:24, 1788:35

Victorian [24] -

1697:16, 1697:37,

1700:43, 1708:15,

1710:43, 1711:29,

1756:7, 1756:16,

1756:21, 1759:21,

1759:28, 1760:9,

1766:42, 1767:8,

1770:2, 1773:33,

1775:18, 1775:29,

1776:3, 1784:14,

1785:30, 1787:13,

1788:4, 1795:47

Victorians [2] -

1704:38, 1770:40

VICTORIA’S [1] -

1696:5

view [31] - 1704:11,

1706:30, 1708:23,

1710:29, 1712:10,

1716:23, 1716:41,

1718:7, 1718:32,

1721:5, 1721:6,

1723:27, 1727:14,

1729:26, 1729:41,

1736:11, 1736:19,

1743:3, 1748:9,

1772:19, 1773:16,

1777:17, 1781:31,

1783:42, 1785:44,

1786:7, 1791:36,

1794:31, 1796:40,

1798:35, 1800:41

views [10] - 1703:33,

1708:40, 1708:41,

1754:28, 1784:21,

1785:23, 1790:9,

1790:17, 1790:32,

1794:34

Vincent [1] - 1713:39

Violence [1] - 1782:35

violence [3] - 1717:37,

1722:5, 1772:41

virtue [1] - 1798:46

vis-à-vis [1] - 1701:47

visibility [8] - 1735:42,

1743:34, 1753:35,

1753:37, 1753:39,

1754:14, 1754:20,

1754:25

visible [1] - 1740:37

vision [3] - 1740:21,

1742:7, 1778:45

visions [1] - 1751:37

visiting [1] - 1736:2

vital [3] - 1741:41,

1745:33, 1763:9

volatility [1] - 1796:20

voluntarily [1] -

1758:32

volunteers [1] -

1714:43

VPS [1] - 1711:30

W

wait [6] - 1778:41,

1781:39, 1794:13,

1794:15, 1794:37,

1794:45

waiting [6] - 1723:38,

1744:10, 1744:17,

1794:28, 1794:39,

1795:43

waits [1] - 1771:36

walk [1] - 1730:17

ward [1] - 1753:28

wards [1] - 1753:30

WAS [1] - 1804:14

watching [1] -

1729:24

wave [2] - 1740:8,

1778:40

waves [1] - 1778:38

ways [2] - 1760:13,

1773:16

wealth [1] - 1800:45

week [2] - 1708:35,

1727:19

weight [1] - 1741:10

Weir [1] - 1762:32

welcome [2] -

1779:45, 1781:31

well-established [1] -

1780:29

wellbeing [3] -

1707:28, 1708:36,

1802:47

Western [3] - 1719:26,

1742:45, 1753:22

whereby [1] - 1712:17

whilst [1] - 1795:4

whole [35] - 1702:45,

1703:28, 1710:29,

1710:37, 1714:17,

1716:17, 1716:22,

1716:42, 1716:43,

1717:15, 1724:12,

1725:22, 1725:23,

1727:30, 1727:31,

1728:9, 1733:42,

1741:9, 1751:46,

1761:2, 1764:5,

1766:17, 1766:27,

1766:38, 1766:39,

1767:23, 1768:21,

1770:19, 1771:47,

1777:31, 1781:29,

1783:21, 1783:35,

1795:41, 1796:45

whole-of-

government [5] -

1710:29, 1766:27,

1770:19, 1781:29,

1783:35

wide [2] - 1770:43,

1785:25

wider [1] - 1796:4

wildly [1] - 1770:20

Williams [6] -

1736:31, 1736:40,

1736:44, 1752:18,

1752:22, 1755:23

WILLIAMS [1] -

1736:42

Williams' [1] - 1796:13

willing [1] - 1751:26

WIT.0001.0064.0001

[1] - 1697:35

WIT.0002.0020.0001

[1] - 1737:1

WIT.0002.0021.0001

[1] - 1713:19

WIT.0003.0006.1000

[1] - 1756:28

WITHDREW [4] -

1713:8, 1736:26,

1755:26, 1804:10

WITNESS [5] -

1710:39, 1713:8,

1736:26, 1755:26,

1804:10

witness [14] - 1697:2,

1713:5, 1713:10,

1735:36, 1736:30,

1736:39, 1755:20,

1755:35, 1759:37,

1763:22, 1781:28,

1783:8, 1784:38,

1804:7

witnesses [2] -

1764:40, 1804:12

wonder [1] - 1703:15

wondered [1] - 1704:5

words [4] - 1709:23,

1766:10, 1768:18,

1785:11

work-in-progress [1] -

1781:36

workforce [3] -

1712:33, 1755:5,

1802:4

Workforce [1] -

1760:5

works [2] - 1751:44,

1762:41

world [3] - 1708:11,

1770:23, 1797:30

worth [3] - 1701:30,

1704:2, 1798:12

worthy [1] - 1751:38

wraps [1] - 1704:41

write [1] - 1711:47

writing [1] - 1712:5

wrote [1] - 1741:7

Y

Yarra [1] - 1696:11

year [34] - 1706:11,

1712:4, 1715:19,

1715:32, 1717:14,

1717:31, 1718:1,

1719:13, 1725:11,

1725:12, 1725:28,

1727:13, 1728:4,

1731:4, 1731:5,

1746:39, 1746:47,

1752:36, 1752:42,

1777:33, 1792:32,

1792:46, 1793:41,

1793:42, 1793:43,

1793:47, 1796:23,

1802:13, 1802:14,

.25/07/2019 (18)


34

1802:15, 1803:2,

1803:38

year's [3] - 1717:10,

1792:26, 1792:29

year-on-year [1] -

1792:46

years [40] - 1699:13,

1700:26, 1702:34,

1704:2, 1705:35,

1706:35, 1707:22,

1712:43, 1713:46,

1724:9, 1730:34,

1730:36, 1731:2,

1731:9, 1736:16,

1737:26, 1737:29,

1737:31, 1737:32,

1737:33, 1737:36,

1742:29, 1742:42,

1743:4, 1743:28,

1744:13, 1747:16,

1751:19, 1751:20,

1754:33, 1754:43,

1769:24, 1775:16,

1776:33, 1777:17,

1783:36, 1784:27,

1786:43, 1792:33

years' [2] - 1697:25,

1770:5

yet" [1] - 1766:10

yield [1] - 1770:45

Yooralla [1] - 1737:16

young [10] - 1700:39,

1700:43, 1701:17,

1701:22, 1754:6,

1758:4, 1759:36,

1790:3, 1790:6,

1790:18

Youth [3] - 1698:36,

1700:33, 1704:1

youth [4] - 1700:37,

1701:3, 1701:7,

1790:23

Z

Zealand [8] - 1707:28,

1708:31, 1710:42,

1710:45, 1711:6,

1711:13, 1711:24,

1770:24

Zero [1] - 1780:46

zero [1] - 1790:40

royal commission into victoria’s mental health system · 2019-07-26 · .25/07/2019 (18)...

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